NPT or PT is considered not medically necessary if the member is actively abusing substances, is having acute withdrawal symptoms, or has recently entered recovery, because test results may be invalid.( Note: PT may be medically necessary to differentiate chronic fatigue syndrome from psychiatric diagnoses when criteria for PT are met.) NPT is considered not medically necessary for diagnosis and management of persons with chronic fatigue syndrome, and evaluation of migraineurs.NPT or PT involving standardized parent interviews and direct, structured behavioral observation for the diagnosis of pervasive developmental disorders (see CPB 0648 - Autism Spectrum Disorders).However, referral to an outpatient mental health provider or outpatient chemical dependency rehabilitation may be considered medically necessary for the evaluation and comprehensive bio-psychosocial treatment for these disorders in collaboration with primary care physicians and other specialists. NPT or PT is rarely considered medically necessary for uncomplicated cases of attention deficit disorder with/without hyperactivity (ADHD). NPT may be considered medically necessary for neurologically complicated cases of ADHD, (e.g., post head trauma, seizures). NPT to distinguish attention deficit/hyperactivity disorder (ADHD) from learning disabilities or language/communication disorders when such distinction remains unclear after history and examination.An evaluation by a psychologist or psychiatrist is sometimes required (for an example, see CPB 0157 - Obesity Surgery). NPT and PT generally are not considered medically necessary for pre-surgical clearance. The testing techniques are both validated for the age and population of the member and they are the most updated version of the instrument and.Testing is needed to develop treatment recommendations after the member has been tried on various medications and/or psychotherapy, has not progressed in treatment, and continues to be symptomatic and.Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility or.NPT or psychological testing (PT) when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation when:.Monitoring of the progression of cognitive impairment secondary to neurological disorders.Differential diagnosis between psychogenic and neurogenic syndromes.Assessment of neurocognitive functions to assist in the development of rehabilitation and/or management strategies for persons with diagnosed neurological disorders.Assessment of neurocognitive abilities following traumatic brain injury, stroke, or neurosurgery or relating to a medical diagnosis, such as epilepsy, hydrocephalus or AIDS.The instruments selected have the empirically substantiated reliability, validity, standardized administration and clinically relevant normative data to assess the diagnostic question or treatment planning goals.Įxamples of medically necessary indications for NPT testing include, but are not limited to:.The testing techniques submitted are both validated for the age and population of the member and they are the most updated version of the instrument and.The testing techniques do not represent redundant measurements of the same cognitive, behavioral or emotional domain and.The testing techniques are validated for the proposed diagnostic question or treatment plan and.The number of hours or units requested for testing does not exceed the reasonable time necessary to address the clinical questions with the identified measures and.Neuropsychological testing (NPT) when provided to aid in the assessment of cognitive impairment due to medical or psychiatric conditions, when all of the following criteria are met:. This Clinical Policy Bulletin addresses neuropsychological and psychological testing.Īetna considers the following neuropsychological and psychological testing medically necessary (unless otherwise stated) when criteria are met: Number: 0158 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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