Currentpriority healthPolicy 91537-R7

Neuropsychological and Psychological Testing

Defines when neuropsychological and psychological testing are considered medically necessary, exclusions, applicable coding, and program-level requirements for Priority Health members and providers.

Policy Summary

Payerpriority health

PolicyNeuropsychological and Psychological Testing

Policy CodePolicy 91537-R7

Change TypeClarification and additions (material link to Provider Manual)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionConsult the Priority Health Provider Manual and submit prior authorization with medical necessity documentation when required.

SourceLink

POLICY UPDATE CHANGES

Added link to Neuropsychological/psychological testing section of Priority Health Provider Manual.

General clarifications to policy language in Section I. POLICY/CRITERIA.

Added Section II. GOVERNMENTAL REGULATIONS.

Enhanced section V. DESCRIPTION.

MultipleApplicable products

96116–96146Procedure codes

F01-F99Diagnosis payment range

Educational/ vocational/ legalCommon exclusions

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Coverage Criteria for Testing

Neuropsychological testing - medically necessary

Covered when ANY of the following clinical situations apply and testing is essential to development of a treatment plan.

Neuropsychological necessity conditions: 1. A significant mental status change not due to a metabolic disorder that has failed to respond to treatment; 2. Need for a pre-surgical or treatment-related cognitive evaluation to inform whether one might safely proceed with a medical or surgical procedure that may affect brain function (e.g., deep brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery, stem cell transplant); 3. Difficulty distinguishing between the neurocognitive effects of a neurogenic syndrome such as dementia versus major depressive disorder when adequate treatment for major depressive disorder has not resulted in improvement in neurocognitive function; 4. A need to determine whether a patient can comprehend and participate effectively in complex treatment regimens (e.g., transplant or bariatric surgeries) in patients with diminished capacity; 5. A significant behavioral change, memory loss or organic brain injury AND ONE of the following: traumatic brain injury, stroke, brain tumor, cerebral anoxic or hypoxic episode, central nervous system (CNS) infection, neoplasms or vascular injury of the CNS, neurodegenerative disorders.

Psychological testing - medically necessary

Covered when ALL of the following are met:

Psychological testing necessity: 1. For diagnostic assessment and differential diagnosis essential to guiding treatment recommendations; 2. Psychological evaluation as a component of a pre-surgical and/or pre-medical program (medical services must be prior-approved by Health Management for consideration of coverage).

Exclusions (Not covered)

Explicit exclusions: Testing performed primarily for educational purposes; testing performed in association with vocational counseling or training; personnel or employment testing; routine batteries of psychological tests given at inpatient admission or continued stay; testing performed solely or primarily for legal/forensic purposes or guardianship evaluation; testing performed when patient is not neurologically and cognitively able to participate in a meaningful way; testing performed when abnormalities of the brain are not suspected; repeated testing when not required for medical decision making; testing administered when the patient has a substance use disorder background and any of the following apply: the patient has ongoing substance use such that test results would be inaccurate, the patient is currently intoxicated; testing performed when the patient has been diagnosed previously with brain dysfunction and there is no expectation that the testing would impact the patient's medical management.

Priority Health does not cover psychological or neuropsychological testing when the service is provided primarily for non-medical purposes or will not affect clinical management. Examples of excluded situations include testing performed primarily for educational purposes, for vocational counseling or training, or for personnel/employment screening. Routine batteries administered solely because of inpatient admission or continued stay, testing performed solely for legal/forensic or guardianship evaluations, and repeated testing that is not required to inform medical decision making are also excluded. Additionally, testing is not covered when the patient cannot meaningfully participate in the testing process, when abnormalities of the brain are not suspected, when the patient is currently intoxicated or has ongoing substance use that would invalidate results, or when a prior diagnosis of brain dysfunction exists and new testing is not expected to change management.

Testing associated with administrative, educational, employment, or social circumstances is specifically not covered. ICD-10 examples listed in the policy include codes for administrative encounters and general examinations (e.g., Z02.*, Z00.8), problems related to education and literacy (Z55.*), problems related to employment (Z56.*), and various psychosocial, upbringing, family support, or other non-medical social circumstances (Z60.*, Z62.*, Z63.*, Z64.*, Z65.*). Claims submitted with these non-medical diagnosis codes may be denied because the testing is considered an administrative or situational evaluation rather than medically necessary clinical assessment.

In addition to the administrative and social examples above, the policy cites specific clinical ICD-10 codes that indicate testing is not covered in certain contexts, such as R41.83 (borderline intellectual functioning) and R45.850–R45.851 (homicidal and suicidal ideations), where the testing requested is not considered appropriate under the coverage criteria.

Applicable Codes

Covered CPT Codes (evaluation services)CPTCovered

96116	Neurobehavioral status exam, per hour of the psychologist's or physician's time
96121	Neurobehavioral status exam, each additional hour
96130	Psychological testing evaluation services; first hour
96131	Psychological testing evaluation services; each additional hour
96132	Neuropsychological testing evaluation services; first hour
96133	Neuropsychological testing evaluation services; each additional hour

Covered CPT Codes (test administration/scoring)CPTCovered

96136	Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional; first 30 minutes
96137	Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional; each additional 30 minutes
96138	Psychological or neuropsychological test administration and scoring by technician; first 30 minutes
96139	Psychological or neuropsychological test administration and scoring by technician; each additional 30 minutes
96146	Psychological or neuropsychological test administration, single automated standardized instrument via electronic platform, automated result only

Diagnosis codes (behavioral health payment and ICD-10 not-covered examples)ICD-10

F01-F99	Range of behavioral/mental disorder diagnosis codes paid under the behavioral health benefit
R41.83	Borderline intellectual functioning (testing not covered in certain contexts)
R45.850 - R45.851	Homicidal and suicidal ideations (listed among ICD-10 codes not covered for testing)

inv-09: Behavioral health diagnosis payment range — F01-F99

Behavioral health diagnosis payment rangeF01-F99

Applies to behavioral/mental disorder codesRange covers dementia, neurocognitive, mood, psychotic, and other mental disorders coded F01-F99

Payment determination noteClaims submitted with covered diagnosis codes in this range will be paid under the behavioral health benefit

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization may be required for neuropsychological or psychological testing. Consult the Priority Health Provider Manual and submit medical documentation supporting medical necessity when prior authorization is requested.

See Priority Health Provider Manual: Neuropsychological/psychological testing.
Submit clinical documentation demonstrating how testing will impact medical management and treatment recommendations.

Note

Provider Manual Reference

Provider operational note: see Priority Health Provider Manual section on Neuropsychological/psychological testing for full procedural guidance and links to forms and submission processes.

Documentation Required

Prior Authorization and Credentialing Notes

Requests for testing and evaluation must document the clinical indication and the provider’s credentials. Neuropsychologists must meet Priority Health's neuropsychology credentialing criteria to provide testing and evaluation services. Include prior-approval documentation for pre-surgical or pre-medical program evaluations when applicable.

Ensure neuropsychologist credentialing documentation is on file.
For pre-surgical or program evaluations, include Health Management prior-approval number with the request.

Denial Risk

Common Denial Triggers

Common denial triggers include testing performed for non-covered contexts (educational, vocational, employment, legal/forensic, routine administrative batteries) and incomplete documentation that fails to demonstrate suspected brain dysfunction or clinical impact on management. Claims for testing tied to administrative or educational codes (see ICD-10 exclusions) are likely not covered.

Testing primarily for educational or vocational purposes is not covered.
Testing for administrative, employment, or legal/forensic reasons is not covered.
Testing when patient cannot meaningfully participate or when brain abnormalities are not suspected is not covered.
Provide documentation that testing results will affect medical decision making to avoid denials.

Background

Neuropsychological testing is a standardized, performance-based assessment used to evaluate brain–behavior relationships and to identify cognitive deficits associated with neurological conditions. It is intended to measure domains such as attention, memory, language, executive function, visuospatial skills, motor and sensory abilities, and processing speed, and to inform diagnostic clarification, treatment planning, capacity determinations, and monitoring of cognitive change over time. Priority Health considers neuropsychological testing medically necessary when it is essential to development of a treatment plan or to answer specific clinical questions such as distinguishing neurocognitive effects of neurologic disease from psychiatric causes, evaluating cognitive risk prior to neurosurgical or other high-risk procedures, assessing capacity to participate in complex medical regimens, or following acute brain injury (e.g., traumatic brain injury, stroke, CNS infection or neoplasm) where identification of deficits will change management.

Key Definitions

inv-15: Definition — Neuropsychological testing (comprehensive standardized assessment of cognitive domains)

DefinitionA comprehensive, standardized assessment process measuring cognitive domains (attention, memory, language, executive function, motor/sensory, visual-spatial abilities, processing speed, academic skills)

Typical administratorTypically administered by a clinical neuropsychologist with specialized post-doctoral training

PurposeUsed to evaluate brain–behavior relationships, identify cognitive deficits from neurological conditions, monitor disease progression or recovery, and guide treatment planning and rehabilitation

Assessment characteristicsPerformance-based, relies on objective tasks rather than self-report

inv-16: Definition — Psychological testing (assessment of mental health, personality, cognitive abilities)

DefinitionAssessment of mental health, emotional functioning, personality traits, and general cognitive abilities using tools such as intelligence tests, personality inventories, projective tests, behavioral assessments, and symptom checklists

Typical administratorTypically conducted by a clinical psychologist

PurposeUsed to diagnose psychiatric conditions, clarify complex mental health presentations, inform psychotherapy or psychiatric treatment, and support legal or forensic evaluations

Relation to neuropsychological testingBroader category that may overlap with neuropsychological testing (e.g., intelligence testing) but focuses more on emotional/behavioral profiles than on brain-behavior functional impact