Service: Neuropsychological Testing PUM 250-0006 Medical Affairs Policy Medical Policy Committee Approval 03/17/17 Effective Date 07/01/17 Prior Authorization Needed Yes-excluding the neurobehavioral status exam* Disclaimer: This policy is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this policy. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policy in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information. Medical policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical policy and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Description: Neuropsychological tests (NPT) are evaluations designed to determine the functional consequences of known or suspected brain injury or abnormality through testing of the neurocognitive domains responsible for language, perception, memory, learning, problem solving and adaptation. Neuropsychological test batteries usually involve extensive evaluation of multiple cognitive domains (e.g., attention, orientation, executive function, verbal memory, spatial memory, language, calculations, mental flexibility, and conceptualization). These tests are carried out on patients who have suffered neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. They are standardized, objective and quantitative in nature and require patients to directly demonstrate their level of competence in a particular cognitive domain. They are not a substitution for clinical interviews, medical, neurologic, or psychological examinations, or other diagnostic procedures used to diagnose neuropathology. Rather, when used judiciously in patients with particular neuropsychological problems, they can be an important tool in making specific diagnoses or prognoses after neurologic injury, to aid in treatment planning, and to address questions regarding treatment goals, efficacy, and patient disposition. Neuropsychological testing is also used to differentiate psychiatric from neurological disorders. Determining what specific brain functions are compromised, as well as which cognitive functions are intact, can help differentiate between the two types of disorders and predict the effects of remediation. Page 1 of 9
Concussion and Post-concussion syndrome: Neuropsychological testing is increasingly used in assessment and management of sport-related concussion to assist in return to play decisions. There is some evidence that testing such as the ImPACT test may help to improve the accuracy of cognitive assessment post-concussion. There is poor evidence that testing is prognostic for rate of recovery or that it should be used alone as an indicator for return to play or school. There is insufficient evidence that baseline tests alone influence physician decision-making or management of concussion. The validity of pre-competition testing is controversial. Neuropsychological testing and Attention Deficit Hyperactivity Disorder: Diagnosis of ADHD can be accomplished using clinical evaluation procedures including an interview, review of the patient s medical, psychological, academic, and/or employment records, information from collateral sources, screening inventories, substance abuse history and physical exam. Neurologic conditions that can mimic or co-occur with ADHD can be distinguished from ADHD through history and medical examination and specialized psychometric and medical testing. Neuropsychological testing may be indicated in rare circumstances. Indications of Coverage: Note: The provider performing the testing must be a covered provider for the particular illness or injury under the plan, depending on the condition that is being evaluated. A. Neurobehavioral status exam is considered medically necessary to evaluate possible issues with cognitive functioning, determine the need for neuropsychological testing, and/ or evaluate the treatment efficacy of a cognitive issue previously diagnosed (not an all-inclusive list). *The neurobehavioral status exam does not require prior authorization. B. Neuropsychological testing (NPT) is considered medically necessary for the purpose of directing further medical care when all of the following criteria are met: 1. Documentation of a neurobehavioral status exam or thorough evaluation by a neurologist, psychiatrist, or psychologist indicates the need for NPT. 2. When at least one medical condition or situation is present such as but not limited to: a. Head injury (open or closed) b. Stroke c. Brain tumor Page 2 of 9
d. Cerebral anoxic or hypoxic episode e. Severe central nervous system infection f. Neoplasm or vascular injury of the central nervous system g. Neurodegenerative disorders (e.g. Lewy body dementia, primary progressive aphasia) h. Demyelinating diseases (e.g., multiple sclerosis) i. Extrapyramidal diseases (e.g., Parkinson s, Huntington s) j. Metabolic encephalopathy after disease stabilization k. Exposure to agents known to be associated with neurodysfunction, (e.g., intrathecal methotrexate, cranial irradiation, lead poisoning). Occupational hazards such as chronic solvent exposure (if a covered benefit) l. A psychiatric diagnosis has been ruled out, or is not responsive to appropriate treatment and testing is requested to provide a differential diagnosis between a psychiatric and neurologic syndrome that is affecting neurocognitive function. (e.g. Complex ADHD with anxiety disorder; autism or other neurodevelopmental disorders, if the diagnosis is in question). m. The presence of unusual, complex, or co-morbid symptoms requiring clarification that only can be accomplished through neuropsychological testing (e.g. worsening symptoms with appropriate treatment for the presumed diagnosis, or differentiating medication related delirium from a progressive process. 3. The neuropsychological tests employed are likely to produce the diagnostic and treatment clarification required and One of the following conditions or situations: a. When there has been a significant mental status change that is not due to a metabolic disorder (such as a diabetic hypoglycemic episode) and the change has not responded to acute medical therapy, OR Page 3 of 9
b. When there has been a significant behavioral change, memory loss, inability to perform simple calculations or abstract tasks, organic brain injury, sensory illusions, or other serious circumscribed cognitive deficits, AND a comprehensive medical and psychological evaluation has been unable to establish a diagnosis OR c. Neurologically complicated cases of Attention Deficit Disorder with significant co-morbidities when, despite a comprehensive medical and psychological evaluation, the diagnosis has not been clearly established, or appropriate medical therapy has failed OR d. Re-evaluation of an individual with decreasing cognitive function is requested due to a neurological disorder if the results are intended to guide treatment. NOTE: Time needed for NPT testing varies depending upon the number of tests performed as well as the cognitive and health status of the individual being tested. More than 8 hours of testing requires physician review. C. Post-Concussion evaluation: Non-baseline NPT testing (e.g. ImPACT) by a physician, psychologist, or licensed mental health professional for management of concussion is considered medically necessary. Limitations of Coverage: A. Review contract and endorsements for exclusions and prior authorization or benefit requirements. B. If used for a condition/diagnosis other than as listed in the Indications of Coverage, deny as experimental, investigational, and unproven at affect health outcomes. C. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, deny as not medically necessary. If not specified as a health plan exclusion, NPT is considered not medically necessary for any of the following: 1. There is no documentation of thorough medical evaluation by a physician (primary care, specialty, or both) prior to the request. Page 4 of 9
2. Request is solely to confirm the working diagnosis and treatment plan. 3. There is no documentation of how the testing will benefit the development of the treatment plan. 4. Uncomplicated attention deficit disorder with or without hyperactivity (ADD/ADHD). 5. When the individual has been diagnosed with a neuro-developmental disorder (for example, autism or Asperger s syndrome) unless coverage is required by Federal or State mandate. 6. Testing is for requested educational purposes, such as assessment of learning style, learning disability, academic ability, development of an educational plan, or for uncomplicated Attention Deficit Disorder. 7. Testing is for the purpose of obtaining or maintaining employment, or improving job performance. 8. Testing is ordered or requested pursuant to a condition of parole, probation, or in any way related to judicial or legal purposes. 9. Testing is required or requested by a third party, such as a school or place of employment. 10. Testing is solely for documenting or monitoring treatment efficacy. (e.g. Gordon Continuous Performance Test, Test of Variables of Attention, etc. to document effectiveness of ADHD management) 11. Re-testing done within one year without clear clinical justification 12. Baseline neuropsychological testing in asymptomatic persons 13. Routine testing upon admission for a behavioral health condition 14. Testing of members who are currently engaged in substance misuse, are in withdrawal, or who only recently are abstinent from drugs or alcohol, as testing may be unreliable in such situations Documentation Required: Office notes and reports indicating: a. The referral source, and to whom the results will be conveyed. b. The test(s) proposed for evaluation. Page 5 of 9
References: c. The amount of time being requested to complete the evaluation. d. The treatment planning issue that testing is expected to clarify. e. A summary of clinical information, including differential diagnosis, prior evaluation performed to date, and therapies or remediation attempted. 1. American Academy of Clinical Neuropsychology. American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol. 2007 Mar; 21(2):209-31. 2. American Academy of Pediatrics (AAP). Committee on Quality Improvement, Subcommittee on Attention Deficit/Hyperactivity Disorder. Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention Deficit/Hyperactivity Disorder. Pediatrics. 2000; 105(5):1158-1170. 3. American Psychiatric Association. Practice guideline for the Psychiatric Evaluation of Adults. Second Edition. June 2006. Available at: www.psychiatryonline.com/pracguide/pracguidetopic_1.aspx. Accessed: 29 Aug 11. 4. American Psychological Association, Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia (1998). Guidelines for the evaluation of dementia and age-related cognitive decline. Washington, DC: American Psychological Association. Available at: www.apa.org/practice/guidelines/index.aspx. Accessed: 29 Aug 11. 5. Filipek PA, Accardo PJ, Ashwal S, Baranek GT, Cook EH Jr, Dawson G, Gordon B, Gravel JS, Johnson CP, Kallen RJ, Levy SE, Minshew NJ, Ozonoff S, Prizant BM, Rapin I, Rogers SJ, Stone WL, Teplin SW, Tuchman RF, Volkmar FR. Practice parameter: screening and diagnosis of autism: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000 Aug 22; 55(4):468-79. 6. Heilbronner RL, Sweet JJ, Attix DK, Krull KR, Henry GK, and Hart RP. Official position of the American academy of clinical neuropsychology on serial neuropsychological assessments: the utility and challenges of repeat test administrations in clinical and forensic contexts. 2010. The Clinical Neuropsychologist, 24:8, 1267-1278. Available at: www.tandfonline.com/doi/pdf/10.1080/13854046.2010.526785. Accessed: 29 Aug 11. Page 6 of 9
7. Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001 May 8; 56(9):1133-42. 8. 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 Jul; 46(7):894-921. 9. Sweet, Jerry J., et al, National Academy of Neuropsychology/Division 40 of the America Psychological Association Practice Survey of Clinical Neuropsychology in the United States, Part I: Practitioner and Practice Characteristics, Professional Activities and Time Requirements: The Clinical Neuropsychologist, 2002, Vol. 2, pp. 109-127 10. Sweet, Jerry J., et al, National Academy of Neuropsychology/Division 40 of the America Psychological Association Practice Survey of Clinical Neuropsychology in the United States, Part II: Reimbursement Experiences, Practice economics, Billing Practices, and Incomes: Archives of Clinical Neuropsychology, 18 (2003) pp. 557582 11. Lundin, Karen A., DeFilippis, Nick A., Proposed Schedule of Usual and Customary Test Administration Times: The Clinical Neuropsychologist, 1999, Vol. 13, No 4, pp. 433-436 12. Camara, Wayne J., et al, Psychological Test Usage: Implications in Professional Psychology: Professional Psychology: Research and Practice: 2000, Vol 31, No 2, pp. 141-154 13. Institute for Clinical Systems Improvement: Health Care Guidelines: Diagnosis and Management of ADHD in Primary Care for School Age Children and Adolescents, Sixth Edition, January 2005 pp. 1-69 14. Hurley, Gina: National Association of Pupil Services Administrators: The Use of Neuroeducational Evaluations in Public Schools, 2001 http://www.napsa.com 15. Hayes Search and Summary: Gordon Diagnostic System to aid in the assessment of ADHD, February 16; 2005 16. Kirkwood MW, Randolph C, Yeates KO. Returning pediatric athletes to play after concussion: the evidence (or lack thereof) behind baseline neuropsychological testing. Acta Paediatr. 2009 Sep; 98(9):1409-11. Page 7 of 9
17. Mayers LB, Redick TS. Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: psychometric issues. J Clin Exp Neuropsychol. 2012; 34(3):235-42. Epub 2011 Dec 13. 18. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009 May; 19(3):185-200. 19. Hayes Search & Summary. Uses for Immediate Post-Concussion Assessment and Cognitive Testing (Impact) after Sports-Related Head Injury. May 16, 2013. 20. UpToDate Concussion and mild traumatic brain injury. Literature review current through: Dec. 20165. This topic last updated: Apr 29, 2015. 21. UpToDate Postconcussion Syndrome. Literature review current through: Dec 2016. This topic last updated: Oct 10 2013. 22. MCG 21 st Edition: ORG: B-805-T (BHG) Neuropsychological Testing. 23. Hayes Medical Technology Directory. Computerized Neurocognitive Testing (CNT) for Sports-Related Head Injury. Publication Date: January 30. 2014, Annual Review Jan 12, 2017. 24. UpToDate Evaluation of cognitive impairment and dementia. Literature review current through: December 2016. This topic last updated: Aug, 3, 2016. 25. UpToDate. ADHD in children and adolescents: Clinical Features and Diagnosis. Literature current through Dec 2016. Topic last updated Jan 04, 2017 26. UpToDate. Concussion in children and adolescents: Management. Literature review current through Dec 2016. Topic last updated Jan11, 2017 27. Gaudet CE and Weyandt LL. Immediate Post-Concussion and Cognitive Testing (ImPACT): a systematic review of the prevalence and assessment of invalid performance. Clin Neuropsychol. 2017 Jan;31(1):43-58. doi: 10.1080/13854046.2016.1220622. Epub 2016 Aug 10. 28. Hang B, Babcock L, Hornung R, et. al. Can Computerized Neuropsychological Testing in the Emergency Department Predict Recovery for Young Athletes With Concussions? Pediatr Emerg Care. 2015 Oct;31(10):688-93. doi: 10.1097/PEC.0000000000000438. Page 8 of 9
WPS / Arise Review History: Implemented 04/04/14, 04/17/15, 07/01/16, 07/01/17 Reviewed 03/07/14, 03/13/15, 03/11/16, 03/17/17 Revised 03/07/14, 03/13/15, 03/11/16, 03/17/17 Developed Medical Policy 03/07/14, 03/13/15, 03/11/16, 03/17/17 Committee Approval Approved by the Medical Director Page 9 of 9