PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL TESTING GUIDELINES

Transcription

1 OPTUM PSYCHOLOGICAL NEUROPSYCHOLOGICAL TESTING GUIDELINES PSYCHOLOGICAL NEUROPSYCHOLOGICAL TESTING GUIDELINES Guideline Number: BH727PNTG_ Effective Date: February, 2018 Table f Cntents Page INTRODUCTION...1 GUIDING PRINCIPLES...1 DEVELOPMENT APPROVAL, DISSEMINATION, USE...2 EVIDENCE-BASED CLINICAL GUIDELINES...4 REFERENCES...7 HISTORY/REVISION INFORMATION...8 INTRODUCTION The Psychlgical and Neurpsychlgical Testing Guidelines is a set f bjective and evidence-based behaviral health criteria used by medical necessity plans t standardize cverage determinatins, prmte evidence-based practices, and supprt members recvery, resiliency, and wellbeing 1 fr behaviral health benefit plans that are managed by Optum and U.S. Behaviral Health Plan, Califrnia (ding business as OptumHealth Behaviral Slutins f Califrnia ( Optum-CA )). The Psychlgical and Neurpsychlgical Testing Guidelines is derived frm generally accepted standards f practice fr psychlgical and neurpsychlgical testing. These standards include guidelines and cnsensus statements prduced by prfessinal specialty scieties, as well as guidance frm gvernmental surces such as CMS Natinal Cverage Determinatins (NCDs) and Lcal Cverage Determinatins (LCDs). The Psychlgical and Neurpsychlgical Testing Guidelines is als derived frm input prvided by clinical persnnel, prviders, prfesisnal specialty scieties, cnsumers, and regulatrs. Befre using this guideline, please check the member s specific benefit plan requirements and any federal r state mandates, if applicable. GUIDING PRINCIPLES We enable the system f care t becme mre engaging, effective and affrdable by way f three cre cmpetencies r pillars : Care Advcacy, Service System Slutins, and Infrmatin Management & Technlgy. Engagement, evidence-based practices, as well as recvery, resilience, and wellbeing are integral t each f the pillars. Pillar One: Care Advcacy Care Advcacy is a means fr intervening n behalf f members living with a behaviral health issue. We imprve the experience f members living in the cmmunities we serve, using ur managed care tls and techniques t supprt wellbeing. We use Utilizatin Management and the Psychlgical and Neurpsychlgical Testing Guidelines in a fcused and time-limited manner t accmplish a specific sustained and measured imprvement in prvider practice. When that purpse is accmplished we stp. We cnsider the member s presenting symptms, clinical histry, and 1 The terms recvery and resiliency are used thrughut the Psychlgical and Neurpsychlgical Testing Guidelines. SAMHSA defines recvery as a prcess f change thrugh which individuals imprve their health and wellness, live a self-directed life, and strive t reach their full ptential. SAMHSA defines resilience as the ability t adapt well ver time t life-changing situatins and stressful cnditins. The American Sciety f Addictin Medicine defines recvery as a prcess f vercming bth physical and psychlgical dependence n a psychactive substance, with a cmmitment t sbriety, and als refers t the verall gal f helping a patient t achieve verall health and well-being. BH727PNTG_ Page 1 f 8

2 bipsychscial factrs, and authrize services the prvider can ffer t meet the member s immediate needs and preferences, and supprt the member s brader recvery, resiliency and wellbeing gals. Using Utilizatin Management and the Psychlgical and Neurpsychlgical Testing Guidelines reduces undesirable variatin frm evidence-based practice. This is key t imprving quality and affrdability. Pillar Tw: Service System Slutins The purpse f service system management is t imprve the structure f, access t, and the practice within systems f care. We develp and sustain systems f care including services t manage crises and t facilitate recvery, resiliency, and wellbeing. The Psychlgical and Neurpsychlgical Testing Guidelines is used t prmte access t prviders wh can safely, efficiently and effectively cnduct psychlgical and neurpsychlgical testing when the results f a clinical diagnstic interview are incnclusive and additinal infrmatin that can be derived frm testing is needed t establish the member s diagnsis r therwise infrm the treatment plan. At the system level, the infrmatin and decisins derived frm using the Psychlgical and Neurpsychlgical Testing Guidelines prvides us with a surce f infrmatin that is used t align incentives, partner with prviders and imprve quality and affrdability. Pillar Three: Infrmatin Management and Technlgy The purpse f Infrmatin Management & Technlgy is t empwer staff, prviders and members living with a behaviral health issue t create a mre engaging, effective and affrdable healthcare experience and t empwer members in their recvery, resiliency, and pursuit f wellbeing. At the member level, the Psychlgical and Neurpsychlgical Testing Guidelines prvides a cnsistent structure fr cllecting case infrmatin which allws us t cnfirm that services ffered by the prvider can meet a member s immediate needs, identify alternatives that exist in the service system t meet thse needs, and fster the develpment f a persn-centered plan. At the system level, the infrmatin and decisins derived frm using the Psychlgical and Neurpsychlgical Testing Guidelines prvides us with aggregate infrmatin which allws us t better understand ur members needs and experiences with the system f care. This infrmatin is used t evaluate and imprve the adequacy f the service system. DEVELOPMENT APPROVAL, DISSEMINATION, USE The Psychlgical and Neurpsychlgical Testing Guidelines is supprted by written plicies that gvern their develpment, disseminatin and use. Develpment and Apprval Optum uses a three-stage prcess t develp the Psychlgical and Neurpsychlgical Testing Guidelines: 1. Draft Develpment: The Psychlgical and Neurpsychlgical Testing Guidelines is updated annually t reflect changes t the netwrk, advances in evidence-based practice, regulatry requirements, and ther pprtunities t imprve the quality f the Psychlgical and Neurpsychlgical Testing Guidelines. 2. Stakehlder Input: The Psychlgical and Neurpsychlgical Testing Guidelines is further shaped by input is slicited frm clinical persnnel, prviders, prfessinal specialty scieties, members, and regulatrs. 3. Cmmittee Apprval: The final draft is presented t the Behaviral Plicy & Analytics Cmmittee fr apprval. OHBS-CA wrks with Optum t update the Psychlgical and Neurpsychlgical Testing Guidelines t reflect changes t the netwrk, advances in evidence-based practice, regulatry requirements, and ther pprtunities t imprve the quality f the Psychlgical and Neurpsychlgical Testing Guidelines. OHBS-CA wrks with Optum t slicit input frm OHBS-CA s Medical Directr and ther clinical persnnel, prviders, members, and regulatrs. The final draft f the Psychlgical and Neurpsychlgical Testing Guidelines is presented t the OHBS-CA Quality Imprvement Cmmittee fr apprval, and the apprved draft is presented t the OHBS-CA Bard f Directrs fr final apprval. Disseminatin The Psychlgical and Neurpsychlgical Testing Guidelines is available t persnnel, prviders and members n Optum s websites. Printed cpies are prvided upn request. BH727PNTG_ Page 2 f 8

3 Use and Limitatins Care Advcates use the Psychlgical and Neurpsychlgical Testing Guidelines when making medical necessity determinatins and as guidance when prviding referral assistance. Services are medically necessary 2 when they are prvided fr the purpse f preventing, evaluating, diagnsing r treating a mental illness r substance use disrder, r its symptms that are all f the fllwing as determined by us r ur designee, within ur sle discretin: 1. In accrdance with Generally Accepted Standards f Medical Practice. 2. Clinically apprpriate, in terms f type, frequency, extent, site and duratin, and cnsidered effective fr the mental illness, substance use disrder, r its symptms. 3. Nt mainly fr the member s cnvenience r that f the member s dctr r ther health care prvider. 4. Nt mre cstly than an alternative drug, service, r supply that is at least as likely t prduce equivalent therapeutic r diagnstic results as t the diagnsis r treatment f the member s mental illness, substance use disrder, r its symptms. Generally Accepted Standards f Medical Practice are standards that are based n credible scientific evidence published in peer-reviewed medical literature generally recgnized by the relevant medical cmmunity, relying primarily n cntrlled clinical trials, r, if nt available, bservatinal studies frm mre than ne institutin that suggest a causal relatinship between the service r treatment and health utcmes. If n credible scientific evidence is available, then standards that are based n Physician specialty sciety recmmendatins r prfessinal standards f care may be cnsidered. We reserve the right t cnsult expert pinin in determining whether health care services are Medically Necessary. The decisin t apply Physician specialty sciety recmmendatins, the chice f expert and the determinatin f when t use any such expert pinin, shall be within ur sle discretin. We develp and maintain clinical plicies that describe the Generally Accepted Standards f Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supprting ur determinatins regarding specific services. These clinical plicies (as develped by us and revised frm time t time), are available t Cvered Persns n Optum s member web site r by calling the telephne number n the Cvered Persn s ID card. They are available t Physicians and ther health care prfessinals n Optum s prvider website r by calling the telephne number n the Cvered Persn s ID card. Care Advcates use the Psychlgical and Neurpsychlgical Testing Guidelines when making medical necessity determinatins and as guidance when prviding referral assistance. Determinatins f medical necessity are determinatins whether the benefit plan will pay fr any prtin f the cst f a health care service, and s are decisins that are fr payment purpses nly. The member and the member s prvider make decisins abut the actual treatment the member will receive, and s we d nt dictate treatment. When making determinatins abut medical necessity we use the infrmatin prvided t us t ascertain whether services are in accrdance with standards f practice, are clinically apprpriate, nt mainly fr cnvenience, and whether services are cst-effective and prvided in the least restrictive envirnment. Peer Reviewers use the Psychlgical and Neurpsychlgical Testing Guidelines when staffing a case, cnducting a peer review, and as a basis fr adverse medical necessity determinatins. Persnnel use the infrmatin and decisins derived frm using the Psychlgical and Neurpsychlgical Testing Guidelines t identify pprtunities t imprve the adequacy f the service system. Staff must first identify enrllee eligibility, any federal r state regulatry requirements that supersede the Psychlgical and Neurpsychlgical Testing Guidelines and the plan benefit cverage prir t use f this guideline. Other clinical guidelines may apply. The Psychlgical and Neurpsychlgical Testing Guidelines is used flexibly, and is intended t augment but nt replace sund clinical judgment. Use is infrmed by the unique aspects f the case, the member s benefit plan, services the prvider can ffer t meet the member s immediate needs and preferences, alternatives that exist in the service system t meet thse needs, and the member s brader recvery, resiliency and wellbeing gals. Exceptins may be made t the Psychlgical and Neurpsychlgical Testing Guidelines such as when there is a superseding cntractual requirement r regulatin, r when a Medical Directr authrizes a case-specific exceptin frm using evidence- based treatment when the member s cnditin has nt respnded t treatment as anticipated. 2 The definitin f medical necessity may vary by health plan r payr. Hwever, mst definitins f medical necessity center arund care that is essential and apprpriate. BH727PNTG_ Page 3 f 8

4 It is expected that exceptins be carefully thught ut, dcumented and apprved by the respnsible level f management. It is als expected that an effrt will be made t wrk with the prvider t identify an apprpriate level f care and frms f treatment that are mst likely t be effective. While the Psychlgical and Neurpsychlgical Testing Guidelines d reflect Optum s understanding f current best practices in care, it des nt cnstitute medical advice. Optum reserves the right, in its sle discretin, t mdify the Psychlgical and Neurpsychlgical Testing Guidelines as necessary. Psychlgical testing is cnsidered a nn-rutine utpatient service and requires authrizatin/ntificatin unless therwise stated in the cverage dcument. Authrizatin and/r ntificatin fr neurpsychlgical testing are nt rutinely required by Optum unless therwise stated in the cverage dcument. Fr mre infrmatin abut authrizatin and/r ntificatin, please see the Neurpsychlgical Testing FAQ psted n Optum s prvider website at A testing request may be submitted by fax r mail using the Psychlgical and Neurpsychlgical Testing Request Frm. Staff can access the frm n the Optum intranet site. Prviders may access the frm n prviderexpress.cm. A testing request may als be submitted by calling the phne number fr behaviral health services n the member s insurance card. EVIDENCE-BASED CLINICAL GUIDELINES COMMON ADMISSION CRITERIA FOR TESTING The member is eligible fr benefits. The member s cnditin and prpsed services are cvered by the benefit plan. Services are within the scpe f the prvider s prfessinal training and licensure, and test user s qualificatins. Services are: Cnsistent with generally accepted standards f clinical practice; Cnsistent with services back by credible research sundly demnstrating that the services will have a measurable and beneficial health utcme, and are therefre nt cnsidered experimental; Clinically apprpriate fr the member s mental health/substance use disrder, based n generally accepted standards f clinical practice and benchmarks. Prir t testing, a clinical evaluatin f the member is cmpleted by a behaviral health r medical prfessinal wh is the referring prvider r the psychlgist cnducting the psychlgical assessment. The member s cnditin cannt be cnclusively assessed with a standard clinical evaluatin due t the nature f the member s signs and symptms and/r psychlgical and envirnmental factrs (i.e., the factrs leading t the request fr testing). Examples include: A differential diagnsis between mre than ne behaviral health cnditin r between a behaviral health and a medical cnditin cannt be made. The member presents with atypical symptms. COMMON CLINICAL BEST PRACTICES FOR TESTING The clinical evaluatin cmpleted prir t testing: Identifies specific, utstanding clinical questins that must be answered by testing in rder t establish the member s diagnsis r infrm the treatment plan. Verifies that utstanding clinical questins cannt be answered by the clinical evaluatin. Infrms the test battery. The tests in the battery and the number f hurs requested are apprpriate t answer specific clinical questins that culd nt be answered by the clinical evaluatin. The number f hurs includes the ttal time necessary t cmplete face-t-face administratin, scring, interpretatin, and reprt writing up t 150% f the standard administratin time recmmended by the test publisher. A request in excess f 150% f the standard administratin time is supprted by extenuating circumstances with evidence submitted by the prvider. Examples f extenuating circumstances include the fllwing: The member has significant functinal impairment. Examples include but are nt limited t: sensry deficits and/r physical disabilities which necessitate mdificatin in standard BH727PNTG_ Page 4 f 8

5 administratin prcedures; severe ppsitinal behavir; attentinal deficits r develpmental disabilities which require the examiner t prvide frequent re-directin and/r breaks fr the member during testing. Nte: testing shuld nt be cnducted if extenuating circumstances such as these are s severe that it culd reasnably pse a threat t the reliability r validity f test results. The member has an intellectual disability. At least ne (1) hurs f service (i.e., 1 unit) is required. The member has abstained frm using alchl r drugs fr at least six (6) weeks prir t testing, r hwever lng is required fr results t be usefully interpretable. Tests are administered in a variety f face-t-face frmats, including paper-and-pencil, cmputer, and visual aids. The prvider mnitrs administratin t ensure that the member is giving sufficient effrt and attentin t cmpleting the test battery s as t ensure a valid and reliable measure is btained. There is a ratinale fr re-testing if testing was cmpleted within the last six (6) mnths, such as re-testing needed t measure changes in functinal impairment r disease prgressin (e.g., acute head injury, strke, speech, mtr r sensry dysfunctin). PSYCHOLOGICAL TESTING ADMISSION CRITERIA CLINICAL BEST PRACTICES See abve cmmn admissin criteria and cmmn clinical best practices fr testing. The prvider s prfessinal training and licensure include any f the fllwing: A dctral-level psychlgist wh is licensed t practice independently, and demnstrates sufficient training and experience. A psychmetrist r psychmetrician wh administers and scres psychlgical tests under the supervisin f a licensed dctral-level psychlgist, and whse services are billed by the supervising psychlgist. The supervising psychlgist must have face-t-face cntact with the member at intake and during the feedback sessin. The supervising psychlgist is als respnsible fr final test interpretatin, reprt writing, and final signature f apprval. A masters-degreed behaviral health prfessinal whse licensure specifically allws fr prvisin f psychlgical testing services. The masters-degreed prvider has prfessinal expertise in the types f tests/assessments being administered. The masters-degreed prvider is cnducting test administratin, scring and interpretatin in accrdance with licensing standards and psychlgical testing prfessinal and ethical standards. Psychlgical testing related t the treatment f chrnic pain may be cnducted when: There is a need t further assess md and persnality characteristics which may influence the member s experience r perceptin f the basis r tlerance f pain, as well as the member s ability t cpe with his/her pain; OR When the member shws changes in cgnitive r intellectual functining after the lng-term use f alchl, street r prescriptin drugs, r upn the discntinuatin f, r nn-respnse t pain-relieving r psychtrpic medicatins. Psychlgical testing as a cmpnent f pre-surgical evaluatin may be cnducted t rule ut behaviral health cnditins that culd cntraindicate surgery, t determine the member s ability t understand the related risks and benefits r surgery, and/r t evaluate the member s ability t participate respnsibly in pst-surgical recvery behavirs and lifestyle changes. NEUROPSYCHOLOGICAL TESTING ADMISSION CRITERIA CLINICAL BEST PRACTICES See abve cmmn admissin criteria and cmmn clinical best practices fr testing. Neurpsychlgical testing is within the scpe f the prvider s prfessinal training and licensure when the prvider is any f the fllwing: A dctral-level psychlgist wh is licensed t practice independently, and demnstrates sufficient training and experience. A psychmetrist r psychmetrician wh administers and scres psychlgical tests under the supervisin f a licensed dctral-level psychlgist, and whse services are billed by the supervising psychlgist. BH727PNTG_ Page 5 f 8

6 The supervising psychlgist must have face-t-face cntact with the member at intake and during the feedback sessin. The supervising psychlgist is als respnsible fr final test interpretatin, reprt writing, and final signature f apprval. A credentialed psychiatrist wh meets the fllwing requirements: Recgnized certificatin in neurlgy thrugh the American Bard f Psychiatry and Neurlgy; Accreditatin in behaviral neurlgy and neurpsychiatry thrugh the American Neurpsychiatric Assciatin; State medical licensure specifically allwing fr the prvisin f neurpsychlgical testing service(s); Evidence f prfessinal training and expertise in the specific tests and/r assessment measures fr which authrizatin is requested; Physician and supervised psychmetrician(s) adhere t the prevailing natinal prfessinal and ethical standards regarding test administratin, scring, and interpretatin. Medical applicatin f Neurpsychlgical testing may be cvered under the medical benefit fr members with the fllwing cnditins when the result f testing will influence clinical decisin making (fr mre infrmatin, see > Tls & Resurces > Plicies, Prtcls and Guides > Medical & Drug Plicies and Cverage Determinatin Guidelines - Cmmercial > Neurpsychlgical Testing Under the Medical Benefit): Attentin-deficit/hyperactivity disrder (ADHD) when all f the fllwing are present: Specific neurcgnitive behaviral deficits related t ADHD need t be evaluated Testing has been recmmended by a physician and is related r secndary t a knwn r suspected rganic-medical cnditin resulting frm brain injury r disease prcess (e.g., cncussin, intractable seizure disrder, cancer treatment effects, genetic disrders, inbrn errrs f metablism) The scpe f these criteria is applicable nly t neurpsychlgical testing that is cvered by the medical benefit. These criteria d nt apply t evaluate r determine educatinal interventins. Cnfirmed space-ccupying brain lesin including but nt limited t the fllwing: Brain abscess; Brain tumrs; Arterivenus malfrmatins within the brain. Dementia r symptms f dementia such as memry impairment r memry lss (including extrapyramidal disrders such as Parkinsn s disease) that is assciated with a new nset r prgressive memry lss and a decline in at least ne f the fllwing cgnitive dmains (DSM-5): Cmplex attentin; Executive functin; Learning and memry; Language; Perceptual-mtr; Scial cgnitin. Demyelinating disrders, including multiple sclersis Intellectual disability r intellectual develpmental disrder, when all f the fllwing are present: The intellectual disability r intellectual develpmental disrder is assciated with a knwn r suspected medical cause (e.g., traumatic brain injury, in uter txin expsure, early seizure disrder, sickle cell disease, genetic disrders) The intellectual disability r intellectual develpmental disrder meets all f the fllwing criteria (DSM-5): Deficits in intellectual functin, such as reasning, prblem slving, planning, abstract thinking, judgment, academic learning and learning frm experience, cnfirmed by bth clinical assessment and individualized, standardized intelligence testing; Deficits in adaptive functining that result in failure t meet develpmental and scicultural standards fr persnal independence and scial respnsibility. Withut nging supprt, the adaptive deficits limit functining in ne r mre activities f daily life, such as cmmunicatin, scial participatin, and independent living acrss multiple envirnments, such as hme, schl, wrk and cmmunity; Onset f intellectual and adaptive deficits during the develpmental perid BH727PNTG_ Page 6 f 8

7 The scpe f these criteria is applicable nly t neurpsychlgical testing that is cvered by the medical benefit. These criteria d nt apply t evaluate r determine educatinal interventins. Encephalpathy including acquired immundeficiency syndrme (AIDS) encephalpathy, human immundeficiency virus (HIV) encephalpathy, hepatic encephalpathy, Lyme disease encephalpathy including neurbrrelisis, Wernicke s encephalpathy, and systemic lupus erythematsus (SLE) encephalpathy. Neurtxin expsure with at least ne f the fllwing: Demnstrated serum levels f neurtxins Individual with dcumented significant prenatal alchl, drug, r txin expsure Seizure disrder, including patients with epilepsy and patients being cnsidered fr epilepsy surgery Strke Traumatic brain injury (TBI): TBI is defined as a bump, blw, r jlt t the head r a penetrating head injury that disrupts the nrmal functin f the brain. Neurpsychlgical testing is unprven and nt medically necessary fr the fllwing (fr mre infrmatin, see > Tls & Resurces > Plicies, Prtcls and Guides > Medical & Drug Plicies and Cverage Determinatin Guidelines - Cmmercial > Neurpsychlgical Testing Under the Medical Benefit): Baseline neurpsychlgical testing in asymptmatic persns at risk fr sprt-related cncussins Cmputerized neurpsychlgical testing when used alne fr evaluating cncussins Neurpsychlgical testing fr the fllwing diagnses alne withut ther cvered cnditins as nted abve: Headaches, including migraine headache; Histry f mycardial infarctin; Intermittent explsive disrder. Cmputerized cgnitive testing, such as Mindstreams Cgnitive Health Assessment and BrainCare TM. REFERENCES* American Academy f Clinical Neurpsychlgy. Neurpsychlgy mdel LCD Retrieved frm: American Academy f Clinical Neurpsychlgy. Practice guidelines fr neurpsychlgical assessment and cnsultatin. The Clinical Neurpsychlgist 2007; 21(2): American Psychiatric Assciatin. Practice guidelines fr the psychiatric evaluatin f adults (3 rd ed.) 2016; Arlingtn, VA: American Psychiatric Publishing. American Psychiatric Assciatin. Diagnstic and statistical manual f mental disrders (5 th ed.) 2013; Arlingtn, VA: American Psychiatric Publishing. American Psychiatric Assciatin. Guideline Watch: Practice guideline fr the treatment f patients with alzheimer s disease and ther dementias 2014; Arlingtn VA: American Psychiatric Publishing. American Psychlgical Assciatin. Guidelines fr the evaluatin f dementia and age-related cgnitive change. American Psychlgist 2012; 67(1):1-9. American Psychlgical Assciatin. Reprt f the task frce n test user qualificatins 2000; Washingtn, DC: Authr. Bauer RM, Iversn GL, Cernich AN, Binder LM, Ruff RM, & Naugle RI. Cmputerized neurpsychlgical assessment devices: Jint psitin paper f the American Academy f Clinical Neurpsychlgy and the Natinal Academy f Neurpsychlgy. Clin Neurpsychl 2012; 26(2): Centers fr Mericare and Medicaid Services. Lcal cverage determinatin (LCD): Psychlgical and neurpsychlgical testing Retrieved frm: Puente AE, Adams R, Barr WB, Bush SS, NAN Plicy and Planning Cmmittee, Ruff RM, Barth JT, Brshek D, Kffler SP, Reynlds C, Silver CH, Trster AI, & the Natinal Academy f Neurpsychlgy. The use, educatin, training and supervisin f neurpsychlgical test technicians (psychmetrists) in clinical practice. Official statement f the Natinal Academy f Neurpsychlgy. Arch Clin Neurpsychl 2006; 21(8): Turner SM, DeMers ST, Fx HR, & Reed GM. APA s guidelines fr test user qualificatins: An executive summary. American Psychlgist 2001; 56(12): *Additinal reference materials can be fund in the reference sectin(s) f the applicable Level f Care Guidelines BH727PNTG_ Page 7 f 8

8 HISTORY/REVISION INFORMATION Date 01/10/2017 Versin 1 02/07/2018 Versin 2 Actin/Descriptin BH727PNTG_ Page 8 f 8