Psychological Evaluation 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: The patient’s parent has requested reimbursement for an additional 12.5 hours of neuropsychological testing (5 units CPT 96133 and 15 units of CPT 96139 for 27 total hours/41 units).Findings: The physician reviewer found that Health Plan approved 14.5 out of the 27 hours of neuropsychological testing requested. Given that the diagnosis of attention deficit hyperactivity disorder (ADHD) is most often a clinical diagnosis and does not require neuropsychological testing to confirm, Wechsler Individual Achievement Test, 5th Edition (WIAT-5) and Conners Continuous Performance Test, 3rd Edition (CPT-3) testing were not medically necessary.

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.

Findings: The physician reviewer found that the patient requested authorization and coverage for an additional two (2) units of psychological testing evaluation and two (2) units of administration/scoring.The submitted documentation does not support the medical necessity of the services at issue. In this case, the provider requested 12 hours of testing and interpretation/scoring to complete 16 assessments to rule out a Post Traumatic Stress Disorder (PTSD) diagnosis. These assessments included several attention and autism-specific tests, but nothing specific to evaluating PTSD. It is unclear what the provider is assessing for and how they plan to rule out PTSD with the assessments selected.

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 Psychological Evaluation, then check the rights and deadlines that apply to your plan.