Commercial

Medical Policy

Notification

Neuropsychological Testing for Neurologically Based Conditions

Notification Issue Date:

This version of the policy will become effective 02/06/2023.

This policy was updated to delineate/clarify circumstances that do not meet the medical necessity criteria for Neuropshysiological Testing.

Title:

Neuropsychological Testing for Neurologically Based Conditions

Policy #:

07.03.08o

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

MEDICALLY NECESSARY

Neuropsychological testing using the most recent version of a valid and reliable test for neurologically based conditions is considered medically necessary, and, therefore, covered when ALL of the following are met:

The reason for testing must be based on a specific referral question and this specific referral question(s) cannot be answered adequately by means of clinical interview and/or behavioral observations.
The testing results based on this referral question(s) are reasonably expected to provide information that will effectively guide the course of treatment.
The individual is neurologically and cognitively able to understand and participate in all activities that are necessary to perform neuropsychological testing, and the individual has a primary medical diagnosis with at least one of the following documented indications:

AND meets at least one of the following rationale for testing:

When the results of standard mental status testing of cognitive function or clinical interview are ambiguous or equivocal, and a neuropsychological assessment is needed to establish the presence of abnormalities or distinguish them from changes that may occur with normal aging, or the expected progression of other disease processes
When neuropsychological data can be combined with clinical, laboratory, and neuroimaging data to assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect central nervous system (CNS) functioning
When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, especially when the information will be useful in determining a prognosis or informing treatment planning by determining the rate of disease progression
When there is a need for a presurgical or treatment-related cognitive evaluation to determine 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 or stem cell transplant) or significantly alter an individual’s functional status
To establish a baseline in the individual's brain functioning for either of the following:

Prior to a neurosurgical procedure (e.g., epilepsy surgery, deep brain stimulation, surgical treatment of a brain tumor, hemorrhage, other lesion, hydrocephalus)
Prior to the initiation of medication for a neurological condition (e.g., Parkinson's disease)

When there is a need to assess the potential impact of adverse effects of therapeutic substances that may cause cognitive impairment (e.g., radiation, chemotherapy, antiepileptic medications), especially when this information is utilized to determine treatment planning
When there is a need to monitor progression, recovery, and response to changing treatments, in individuals with CNS disorders, in order to establish the most effective plan of care
When there is a need for objective measurement of the individual's subjective complaints about memory, attention, or other cognitive dysfunction, which serves to determine treatment by differentiating psychogenic from neurogenic syndromes (e.g., dementia vs. depression)
When there is a need to establish a treatment plan by determining functional abilities/impairments in individuals with known or suspected CNS disorders
When there is a need to determine whether an individual can comprehend and participate effectively in complex treatment regimens (e.g., surgeries to modify facial appearance, hearing, or tongue debulking in craniofacial or Down syndrome patients; transplant or bariatric surgeries in individuals with diminished capacity), and to determine functional capacity (e.g., for healthcare decision making, work, independent living, managing financial affairs)
When there is a need to design, administer, and/or monitor outcomes of medically necessary cognitive rehabilitation procedures (e.g., compensatory memory training for brain-injured individuals)
When there is a need to establish treatment planning through identification and assessment of the neurocognitive sequelae of systemic disease (e.g., hepatic encephalopathy or anoxic/hypoxic injury associated with cardiac procedures)
When there is a need for assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychological disorders
When there is a need to diagnose cognitive or functional deficits in children and adolescents based on the inability to develop expected knowledge, skills, or abilities as required to adapt to new or changing cognitive, social, emotional, or physical demands
To diagnose and/or manage the neurocognitive effects of medical conditions such as, but not limited to, the following:

Based on currently accepted standards of practice, testing beyond 8 hours is typically not necessary. Supporting documentation in the medical record must be present to justify greater than 8 hours per individual per evaluation. When testing is performed over several days, the cumulative testing time must be reported on the same claim form upon completion of the testing; each hour of service should be reported as one unit.

REPEAT NEUROPSYCHOLOGICAL TESTING
Repeat neuropsychological testing is considered medically necessary and, therefore, covered when needed to assess or determine a treatment change, when there is a reasonable suspicion of a new problem or when needed to reconfirm a diagnosis (e.g., following deterioration or change of the individual’s condition) and the results of testing are expected to provide information that will effectively guide the course of treatment.

COMPUTER-BASED NEUROPSYCHOLOGICAL TESTING
Computer-based neuropsychological testing (e.g., Impact™, Headminder®, Wisconsin Card Sorting Test) is considered medically necessary and, therefore, covered as an adjunct to conventional testing (e.g., standard examiner-administered tests, clinical assessment) for the assessment of cognitive impairment.

NEUROPSYCHOLOGICAL TESTING AND SPECIALTY PROVIDER GROUPS
Certification granted by the American Board of Professional Psychology (ABPP) and the American Board of Professional Neuropsychology (ABN) are the accepted standard of board certifications and specialty training. Neuropsychological evaluation/testing for neurologically based conditions must be performed directly by a certified, state licensed professional provider or a trained technician under the direct supervision of a professional provider in any of the following specialty groups:

Neurology
Psychiatry
Psychology

Any aspects of the test conducted by an individual not certified require the direct supervision of a professional provider certified by the ABPP or ABN to ensure the appropriate interpretation and reporting of findings. The certified professional provider must be immediately available to furnish assistance and direction throughout the test administration. The certified professional provider is not required to be present in the room where the testing is being performed or within any other physical boundary as long as the professional provider is immediately available.

Neuropsychological tests (see Guidelines) must be standardized, valid, and reliable in order to answer the specific clinical question for the specific population under consideration. The most recent version of the test must be used.

NOT MEDICALLY NECESSARY

Neuropsychological testing is considered not medically necessary and, therefore, not covered for any of the following circumstances because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury:

When the individual is not neurologically and cognitively able to participate in a meaningful way in the testing process
When the test is used solely as a screening tool given to the individual or to general populations
When abnormalities of brain function are not suspected
When testing is used for self-administered or self-scored inventories, or screening tests of cognitive function (whether paper and pencil or computerized), (e.g., Abnormal Involuntary Movement Scale [AIMS] or Folstein Mini–Mental Status Examination [MMSE])
When repeat of test is not required for medical decision-making (i.e., making a diagnosis or deciding whether to start or continue a particular rehabilitative or pharmacologic therapy)
When administered when the individual has a substance abuse background and any of the following apply:

The individual has ongoing substance abuse such that test results would be inaccurate
The individual is currently intoxicated

When the individual has been diagnosed previously with a brain dysfunction (e.g., Alzheimer’s disease), and there is no expectation that the testing would impact the individual's medical management
When testing is primarily for the purpose of determining if an individual is a candidate for a non-neurological medical or non-neurological surgical procedure
When the testing is primarily for diagnosing attention-deficit hyperactivity disorder (ADHD), unless the diagnostic interview, clinical observations, and results of appropriate behavioral rating scales are inconclusive
When the requested tests are experimental, antiquated, or not validated
When the testing is made prior to the completion of a diagnostic interview by a behavioral health provider
When two or more tests measure the same functional domain
When the number of hours requested for the administration, scoring, interpretation, and reporting exceeds the generally accepted standard for the specific testing instrument(s), unless justified by particular testing circumstances
When the testing is performed to determine if an individual is a candidate for a specific medication or dosage
When the use of structured interview tools or interviews do not have psychometric properties or normative comparisons
When there is not a reasonable suspicion of a new problem, relapse, or deterioration in condition
When testing is used for the following conditions (such as, but not limited to), unless an associated neurologically based medical condition is suspected or exists and is documented in the individual's medical record:

SCREENING EXAMINATIONS

Screening examinations (e.g., the MMSE or the Neurobehavioral Cognitive Status Examination [NCSE], are considered part of the overall comprehensive neuropsychological testing and are, therefore, not separately reimbursed. These simple screening examinations do not qualify as comprehensive neuropsychological testing.

BENEFIT EXCLUSION

Neuropsychological testing is considered a benefit contract exclusion and is, therefore, not covered when performed for any of the following non-medical indications such as, but not limited to:

Employment
Disability qualification
Legal/court related purposes (e.g., custody evaluation, parenting assessments, or other court- or government-ordered or requested testing)
As a screening method for any purpose (e.g., educational purposes, solely as a screening test for Alzheimer's disease)

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Portions of the neuropsychological testing battery may be administered either by a computer or by a technician under the direction of an appropriately trained professional provider. Each portion of the test should be reported using the Current Procedural Terminology (CPT) code that appropriately represents the service performed.

For computer-based tests (such as Impact™, Headminder®, or Wisconsin Card Sorting Test), any eligible professional provider specialty type (including, but not limited to, a sports medicine physician) should report these tests using CPT code 96120. This code is not an hourly code; it should be reported only once per testing session.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, neuropsychological testing is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

NEUROPSYCHOLOGICAL TEST SELECTION

Neuropsychological testing consists primarily of individually administered tests that comprehensively sample ability domains that are known to be sensitive to the functional integrity of the brain. There are numerous components of neuropsychological testing, and it is the responsibility of the professional provider to determine which tests are most appropriate for each individual. Each individual does not need the full battery of tests; some individuals may only need a subset of tests.

Neuropsychological tests include direct question-and-answer; object manipulation; inspection and responses to pictures or patterns; or paper-and-pencil written or multiple-choice tests that measure functional impairment and abilities in:

General intellect
Reasoning, sequencing, problem-solving, and executive function
Attention and concentration
Learning and memory
Language and communication
Visual-spatial cognition and visual-motor praxis
Motor and sensory function
Mood, conduct, personality, quality of life
Adaptive behavior (activities of daily living)
Social-emotional awareness and responsivity
Psychopathology (e.g., psychotic thinking or somatization)
Motivation and effort (e.g., symptom validity testing)

Description

NEUROPSYCHOLOGICAL TESTING

Neuropsychological testing is the in-depth assessment of an individual's brain function abilities and mental status. Neuropsychological testing mainly focuses on cognitive capabilities, such as memory and attention, but may also include personality functioning and mood, social behavior, emotional status, motor skills, language, visual perception, and adjustment to limitations. Neuropsychological testing provides the basis for the conclusions regarding neurocognitive effects of various medical conditions. Neuropsychological testing should be delayed until any acute changes have stabilized following trauma, infections, or metabolic or vascular insults to the central nervous system. The goal of neuropsychological testing may be clarification of a diagnosis, determination of the clinical and functional significance of a brain abnormality, or the development of recommendations regarding neurological rehabilitation planning, but always for the purpose of developing a treatment plan. It is frequently a part of the overall neurodiagnostic assessment, which may include other neurodiagnostic testing such as computed tomography (CT), magnetic resonance imaging (MRI), electroencephalogram (EEG), and single-photon emission computed tomography (SPECT).

Neuropsychological testing is typically directed by the types of questions asked at the time of the referral, which should ideally include the following:

General information about the individual (e.g., age, education, medical and psychiatric history)
Reasons why the evaluation is requested
A description of the problem to be assessed
Any pertinent history (e.g., known substance abuser, physical limitations [e.g., hemiparesis, blindness, hearing impaired])
Relevant lab work-up
Findings of prior structural or functioning imaging

Neuropsychological testing provides quantitative measurements that are compared to normative values. The data provided by the neuropsychological testing can be used to compare an individual's present function to some point in the future or the past, but also involves comparison to standardized data from samples of normal individual.

Neuropsychological testing employs a variety of fixed or flexible batteries of tests. A fixed battery provides a standardized and broad approach to measuring cognitive function that can be applied to a range of disorders requiring assessment. The most commonly used fixed neuropsychological testing is the Halstead-Reitan Neuropsychological Test Battery, a set of six tests that measure multiple neurocognitive domains. Although it is comprehensive, not all the resulting data may be pertinent. Most neuropsychologists choose to perform a flexible subset of tests from within a fixed battery, an individualized approach that focuses on the specific areas of cognitive function in question. The choice of a fixed versus flexible battery is based on the neuropsychologist's review and assessment of the individual's history. Typical subset tests employed include the Wechsler Adult Intelligence Scale Revised (WAIS-R), Boston Diagnostic Aphasia Examination (BDAE), Rey Auditory Verbal Learning Test (RAVLT), Wisconsin Card Sorting Test (WCST), and the Rey Complex Figure Test.

Simple screening tests such as the Mini–Mental State Examinations (MMSE) and the Neurobehavorial Cognitive Status Examination (NCSE) do not qualify as comprehensive neuropsychological testing.

There are a number of computerized test batteries, individual tests, and scoring programs. These are generally not used in lieu of a battery of tests administered by a neuropsychologist or technician, but serve as an adjunct.

Neuropsychological testing should be performed by a qualified, credentialed clinician. Certification granted by the American Board of Professional Psychology (ABPP) and the American Board of Professional Neuropsychology (ABN) are the accepted standards of board certification and specialty training. Aspects of the test conducted by an individual not certified requires the direct supervision of a professional certified by the ABPP or ABN to ensure the appropriate interpretation and reporting of findings.

Individuals referred for neuropsychological testing are usually classified as one of three groups. The first group, and probably the largest, consists of individuals with a known brain disorder. The most common brain disorders are cerebrovascular disorders, head injury, hydrocephalus, Alzheimer's disease, Parkinson's disease, multiple sclerosis, tumors, seizures, and infections. A neuropsychological evaluation may be useful in defining the nature and severity of the individual's functional problem. The assessment would provide useful information about the individual's cognition, personality characteristics, social behavior, emotional status, and adjustment to limitations.

The second group consists of individuals with a known risk factor for brain disorders. This would involve a change in behavior possibly resulting from a disease or injury to the brain (i.e., a blow to the head from an automobile accident). For these individuals, neuropsychological testing may be used to provide evidence of brain dysfunction and to describe the nature and severity of problems. An evaluation would focus on divided attention, sustained concentration and mental tracking, and memory.

Lastly, the third group consists of those with a suspected brain disease or trauma based on the observation of a change in a person's behavior without an identifiable etiology. The individual has no risk factors for brain disorder, and this diagnosis is being considered on the knowledge that all other disorders have been excluded.

NEUROPSYCHOLOGICAL TESTING FOR PROPOSED CONDITIONS
Although neuropsychological testing has been proposed to play a role in the evaluation of various conditions, the following conditions are examples of where there is insufficient clinical evidence to demonstrate that neuropsychological testing is useful in clinical decision making or will improve management of such conditions.

Neuropsychological testing has been proposed in the evaluation of autism spectrum disorders (ASD). Autism spectrum disorder is characterized by persistent deficits in social communication and social interactions across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing, maintaining, and understanding relationships. In addition, ASD is characterized by restricted, repetitive patterns of behavior or interests. Symptoms cause clinically significant impairment of functionality. There is no reported evidence that confirms or excludes a diagnosis of autism based on cognitive patterns alone. As previously noted, neuropsychological testing consists of the administration of a series of standardized tests of differing mental functions and the interpretation of the findings so that inferences about brain function can be made. There is insufficient available published peer-reviewed literature to support standard use of neuropsychological testing for individuals with ASD; however, neuropsychological testing may be helpful in evaluating specific neurologic conditions that are present in an individual with suspected ASD. The gold standard diagnostic tools in research and clinical assessment of ASD are the Autism Diagnostic Observational Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R). These instruments alone do not determine diagnostic status. Rather, results obtained guide clinical decision making for assigning an ASD diagnosis.

It has also been proposed that neuropsychological testing be used in the assessment of attention deficit disorders with or without hyperactivity (ADHD). Attention deficit disorder causes clinically significant impairment in social, academic, or occupational functioning in settings such as school, work, and/or home. Although there is no specific test to confirm a diagnosis of ADHD, the diagnosis is applied to children and adults who display certain characteristic behaviors over a period of time. There is much less evidence for the utility of neuropsychological testing in management of ADHD than there is for many other medical conditions (Pritchard et al., 2012) and tests of executive functions have often been found to be poor predictors of functional impairment in the disorder (Barkley and Murphy, 2010; Jonsdottir et al., 2006). Further research is needed to better define the role of neuropsychological testing in ADHD (Haavik, 2010; Pineda, 2007). Neuropsychological testing may be helpful in evaluating suspected neurological comorbidities in an individual with suspected ADHD; however, there is no evidence for the use of neuropsychological testing in the evaluation of ADHD where such comorbidities are not suspected.

The available published peer-reviewed literature addressing the neuropsychological consequences of migraine has been inconclusive. The International Headache Society diagnoses a migraine by its pain and number of attacks (at least five, lasting 4-72 hours if untreated), and additional symptoms including nausea and/or vomiting, or sensitivity to both light and sound. Reports of cognitive testing in individuals with migraines and controls have yielded inconsistent results (O'Bryant et al., 2005). Baars et al. (2010) found no evidence that migraine headaches or migraine-related medication use are risk or protective factors for cognitive dysfunction or cognitive deterioration over time. There is insufficient clinical evidence that demonstrates that neuropsychological testing is useful in clinical decision making or will improve management of headaches including migraine headaches.

The available published peer-reviewed literature does not support the use of neuropsychological testing in the diagnosis or treatment of chronic fatigue syndrome (CFS). CFS is a debilitating and complex disorder characterized by intense fatigue that is not improved by bed rest and that may be worsened by physical activity or mental exertion. Individuals with CFS often function at a substantially lower level of activity than they were capable of before they became ill. Because there is no blood test, brain scan, or other lab test to diagnose CFS, it is a diagnosis that can only be made after ruling out other possible illnesses. The current research shows that slowed processing speed, impaired working memory, and poor learning of information are the most prominent features of cognitive dysfunction in individuals with CFS. Furthermore, to this date no specific pattern of cerebral abnormalities has been found that uniquely characterizes CFS individuals. There is insufficient clinical evidence that demonstrates that neuropsychological testing is useful in clinical decision making or will improve management of CFS.

COMPUTERIZED NEUROPSYCHOLOGICAL TESTING

Neuropsychological testing is administered through a variety of modalities, including computers. There is a broad array of tests administered using computerized neuropsychological testing, including Automated Neuropsychological Assessment Metrics (ANAM), CogState®, HeadMinder®, ImPACT™, Conners' Continuous Performance Test-II (CPT-II), Green's Word Memory Test (WMT), and the Wisconsin Card Sorting Test. Computerized neuropsychological tests must meet the same psychometric standards of adequate reliability and validity as examiner-administered neuropsychological tests. The American Psychological Association's standards for educational and psychological testing is generally considered an authoritative source on the development and validation of educational and psychological tests and assessments.

Many of the computer-based neuropsychological tests were developed to evaluate sports-related concussion/mild traumatic brain injury (MTBI). Neuropsychological testing utilized in sports-related concussion/MTBI is distinctly different from the more traditional models of neuropsychological testing described above. Meehan et al. (2012) concluded that when used appropriately by trained personnel, computerized neuropsychological testing is a valuable component of a comprehensive concussion/MTBI management program. The American Academy of Pediatrics published a clinical report (Halstead et al., 2010) for sports-related concussion in children and adolescents stating that neuropsychological testing is one of several tools in the assessment of an athlete with concussion/MTBI, but does not independently determine whether an athlete has experienced a concussion/MTBI or when he or she may safely return to play. Computer-based neuropsychological tests have also been adapted for testing in other conditions associated with cognitive impairment, such as multiple sclerosis, Parkinson's disease, and dementia. Computer-based neuropsychological test results, however, must be interpreted in the context of relevant history, other test findings, other clinical assessments, and data available from other disciplines and should not be used alone for making a diagnosis.

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Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.

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Pritchard A E, Nigro C A, Jacobson L A, et al. The role of neuropsychological assessment in the functional outcomes of children with ADHD. Neuropsychology review. 2012;22(1):54-68.

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Coding

CPT Procedure Code Number(s)

96132, 96133, 96136, 96137, 96138, 96139, 96146

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 07.03.08o:

07/09/2025	This policy has been reissued in accordance with the Company's annual review process.
10/01/2024	This policy has been reissued in accordance with the Company's annual review process. This policy has been identified for the ICD-10 Diagnosis Code update, retroactively effective 10/01/2024 and issued 10/16/2024. The following ICD-10 Diagnosis Code has been added to Attachment A to the policy: F50.84 The following ICD-10 Diagnosis Code narrative has been revised in this policy: FROM: F98.21 Rumination disorder of infancy TO: F98.21 Rumination disorder of infancy and childhood

07/09/2025

This policy has been reissued in accordance with the Company's annual review process.

10/01/2024

This policy has been reissued in accordance with the Company's annual review process.

This policy has been identified for the ICD-10 Diagnosis Code update, retroactively effective 10/01/2024 and issued 10/16/2024.

The following ICD-10 Diagnosis Code has been added to Attachment A to the policy:

F50.84

The following ICD-10 Diagnosis Code narrative has been revised in this policy:

FROM: F98.21 Rumination disorder of infancy

TO: F98.21 Rumination disorder of infancy and childhood

Revisions From 07.03.08n:

10/01/2023

This policy has been identified for the ICD-10 Diagnosis Code update, effective 10/01/2023.

The following ICD-10 Diagnosis Codes has been added to the policy:

G43.E01 Chronic migraine with aura, not intractable, with status migrainosus
G43.E09 Chronic migraine with aura, not intractable, without status migrainosus
G43.E11 Chronic migraine with aura, intractable, with status migrainosus
G43.E19 Chronic migraine with aura, intractable, without status migrainosus

Revisions From 07.03.08m:

08/23/2023	This policy has been reissued in accordance with the Company's annual review process.
02/06/2023	This version of the policy will become effective 02/06/2023. This policy was updated to delineate/clarify circumstances that do not meet the medical necessity criteria for Neuropshysiological Testing.

Revisions From 07.03.08l:

10/01/2022

The following ICD-10 Diagnosis codes have been added to Attachment A of this policy: F10.90, F10.91, F11.91, F12.91, F13.91, F14.91, F15.91, F16.91, F18.91, F19.91, F43.81, F43.89

The following ICD-10 Diagnosis code has been removed from Attachment A of this policy: F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F43.8

Revisions From 07.03.08k:

10/01/2021

This policy has been identified for the ICD-10 Diagnosis code update, effective 10/01/2021.

The following ICD-10 Diagnosis codes have been added to Attachment A of this policy:

F32.A, F78.A1, F78.A9

The following ICD-10 Diagnosis code has been removed from Attachment A of this policy: F78

Revisions From 07.03.08j:

06/02/2021

The policy has been reviewed and reissued to communicate the Company’s continuing position on Neuropsychological Testing for Neurologically Based Conditions.

10/01/2020

This policy has been identified for the ICD-10 Diagnosis code update, effective 10/01/2020.

The following ICD-10 Diagnosis codes have been added to Attachment A of this policy as Not Medically Necessary:

F10.130, F10.131, F10.132, F10.139, F10.930, F10.931,

F10.932, F10.939, F11.13, F12.13, F13.130, F13.131,

F13.132, F13.139, F14.13, F14.93, F15.13, F19.130,

F19.131, F19.132, F19.139, R51.0, R51.9

The following ICD-10 Diagnosis code has been removed from Attachment A of this policy: R51

Revisions From 07.03.08i:

06/03/2020	The policy has been reviewed and reissued to communicate the Company’s continuing position on Neuropsychological Testing for Neurologically Based Conditions.
04/24/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on Neuropsychological Testing for Neurologically Based Conditions.
01/01/2019	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for the CPT HCPCS code update, effective 01/01/2019. The following CPT codes have been deleted from this policy: 96118, 96119, 96120 The following CPT codes have been added to this policy: 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146 ______________________________________ Note: on 03/06/2019 the following CPT codes were deleted from this policy: 96130, 96131. These psychological testing codes were added to this policy in error as part of the 01/01/2019 CPT/HCPCS code update. Retroactively effective to 01/01/2019, these codes have been deemed inappropriate for the purposes of this policy. On 3/13/2019 the following CPT code was deleted from this policy: 96121, Retroactively effective to 01/01/2019, this code has been deemed inappropriate for the purposes of this policy.

Revisions From 07.03.08h:

11/21/2018

The policy has been reviewed and reissued to communicate the Company’s continuing position on Neuropsychological Testing for Neurologically Based Conditions.

10/01/2018

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM codes have been added to this policy:

F12.23, F12.93, Z13.40, Z13.41, Z13.42, Z13.49

The following ICD-10 CM code has been removed from this policy:

Z13.4

Revisions From 07.03.08g:

03/27/2018

This policy has undergone a routine review, and the medical necessity and not medically necessary criteria have been revised to include additional detailed indications/conditions/circumstances for neuropsychological testing.

Applicable not medically necessary ICD-10 CM codes have been added to the policy due to criteria qualifications. Claims submitted for neuropsychological testing must include a primary ICD-10 diagnosis code that represents a neurologically based medical condition.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

10/1/2023

Version Issued Date:

9/29/2023

Version Reissued Date:

7/9/2025