Psychological Testing denials: what the review data shows

Where the denial was overturned

The parent of a three-year-old male has requested psychological testing for evaluation of his autistic disorder. Findings: The physician reviewer found that young children are often referred for psychological evaluation because they appear to have features of autism, which can be difficult to assess given their limited social interaction and communication skills. According to a paper by Akshoomoff, “Many features and behavior problems can further interfere with the accurate assessment of a young child’s cognitive abilities, including difficulty maintaining attention, hyperactivity, sensory issues, and poor compliance, particularly in an unfamiliar setting.” According to Akshoomoff, “it is critical to identify cognitive strengths and weaknesses and developmental delays in a young child suspected of an autism spectrum disorder (ASD) as part of the initial diagnostic workup and to assist wi…

The representative of a 15-year-old male enrollee has requested an additional four hours of psychological testing for an evaluation of the enrollee to rule out Asperger’s disorder. Findings: The physician reviewer found that psychological testing is appropriate in this setting and should include assessment of cognitive ability, verbal and non-verbal IQ and adaptive skills (American Academy of Child and Adolescent Psychiatry Practice Parameters). The article by Troth and King indicates that a comprehensive assessment is needed for Asperger’s syndrome and should include a detailed developmental history, direct observation, evaluation tools specific for autism diagnosis, a review of school records and a consultation with the patient’s teachers (particularly around peer interaction).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for five additional units of psychological testing (12 units total). In this case, a Psychological Evaluation Report dated 4/11/24 indicated that the purpose of the psychological evaluation was to rule out autism and attention deficit hyperactivity disorder (ADHD). However, the assessment completed across both days were geared more toward assessing for ADHD, without autism-specific assessments being completed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Psychological Testing. Findings: The physician reviewer found that sychological testing is to be used in conjunction with other sources of clinical information to create a diagnostic formulation and treatment recommendations. These multiple sources of clinical information include clinical interview, interviews with collateral sources, self-report objective measures, observation of the patient, and review of past records.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Psychological Testingwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.