Neuropsychological Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for an additional 10 units (for a total of 30 units) of neuropsychological testing services. In this case, the patient has medically and surgically refractory epilepsy, and is status post a partial resection of the right frontal lobe, with subsequent implantation of RNS. He continues to have numerous seizures daily, despite the stimulator and multiple anticonvulsant medications. There is concern that he may have reading reflexive epilepsy. He has an SCN1A mutation of uncertain significance. Meisler and colleagues note that mutations of SCN1A genes are responsible for a significant burden of neurological disease. SCN1A mutations have been associated with cognitive decline.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for neuropsychological testing services provided for evaluation of the enrollee’s behavioral health condition. Findings: The physician reviewer found that based on the documentation provided, as well as the medical literature, there is support for a portion of the services at issue in this clinical setting. Per the records, the patient received the following neuropsychological testing: Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV); Woodcock Johnson Test of Academic Achievement, Fourth Edition (WJ-IV); Rorschach Inkblot Test (Rorschach); Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2); Million Clinical Multiaxial Inventory, Third Edition (MCMI-III); Substance Abuse Subtle Screening Inventory, Third Edition (SASSI-3); Autism Diagnostic Observation Schedule (ADOS); and Socia…

Where the denial was upheld

Findings: The physician reviewer found that the patient has requested authorization and coverage for an additional 42 hours of neuropsychological testing services. The American Psychological Association (APA) has established guidelines for the testing and billing of psychological and neurological assessments that include descriptions of the various CPT codes utilized during testing and how they are to be used. In this case, the provider has requested the following codes/units: six units of CPT 96130, 30 units of CPT 96131, five units of CPT 96136, and 25 units of CPT 96137. There are several issues with the units associated with these codes.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for psychoeducational testing services to screen for learning disabilities and/or neuropsychological testing services to screen for pervasive developmental disorder. The records provided for review document that this patient has been assessed and diagnosed with attention-deficit/hyperactivity disorder (ADHD), combined subtype. Learning disabilities frequently co-exist with ADHD but are educational rather than medical in nature. Appropriate evaluation is performed by a psychologist, teacher, and often a speech-language pathologist as part of an individualized education plan (IEP) through the local school district. Interventions for learning disabilities are educational and implemented through the school. There is a lack of specific medical interventions for learning disabilities.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Neuropsychological Testing, then check the rights and deadlines that apply to your plan.