Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an additional seven units of neuropsychological evaluation (five hours of CPT 96133 and two hours of CPT code 96137).At issue in this case is whether the additional seven units of neuropsychological evaluation (five hours of CPT 96133 and two hours of CPT code 96137) to treat the enrollees mental health or substance use disorder are medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The American Academy of Child and Adolescent Psychiatry (AACAP) published practice parameters note that neuropsychological testing is not required as part of a routine assessment for ADHD, but may be indicated when there is strong evidence of a neurological disorder. Additionally, the AACAP did not recommend neuropsychological testing for the assessment and treatment of children and adolescents with depressive disorders. Learning disabilities frequently co-exist with ADHD, but are educational rather than medical in nature. Appropriate evaluation is performed by a psychologist, teacher and often a speech-language pathologist as part of an Individualized Education Plan through the local school district. Interventions for learning disabilities are educational and implemented through the school. There are no specific medical interventions for learning disabilities. In this case, the patient does not appear to have an underlying neurological disorder based on the documentation. Additionally, there is no documentation of cognitive or developmental regression. Moreover, the episodes of muscle twitching do not appear to be seizures. Records also reflect that an episode was captured on EEG but did not have correlation with seizure or epileptiform activity. No other neurological symptoms are described. In this patients case, an additional seven units of neuropsychological evaluation are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, an additional seven units of neuropsychological evaluation (five hours of CPT 96133 and two hours of CPT code 96137) are not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.