Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health/Post Traumatic Stress Disorder (PTSD)
Treatment: Diagnostic Testing
The health plan denied the requested psychological and neuropsychological diagnostic testing as not medically necessary. 
The health plan's determination is overturned.

The case involves a male who was referred for psychological and neuropsychological testing to address diagnostic considerations and treatment issues in a case with anxiety, depression, and comorbid posttraumatic stress disorder (PTSD), as well as a history of obsessive-compulsive disorder (OCD) and delayed speech development. The patient was referred for testing after a neurology consult that identified problems with attention, memory and interpersonal functioning. The testing was to assist in differential diagnosis. Additionally, the patient was planning to attend graduate school and was requesting a reasonable accommodation for his mental disorders/disability. Thus, the psychological and neuropsychological testing served the purpose of affirming a diagnosis with differential diagnosis and providing documentation to his school's disability office in order to obtain reasonable accommodation.

The patient did report weekly use of cannabis (marijuana) and social alcohol use. However, he denied use of other substances and had no formal substance use disorder diagnosis. The patient had been treated with psychotherapy including eye movement desensitization and reprocessing (EMDR) and hypnotherapy, as well as medications that were minimally helpful.

The patient underwent a diagnostic interview and was administered the following tests: grooved pegboard, Wisconsin Card Sorting, comprehensive trail making, medical symptom validity, Connor's performance and auditory evaluation, Rey complex figure test and recognition trial, and the Woodcock-Johnson test of cognitive abilities.

The health plan's determination of medical necessity is overturned. This answer is consistent with the relevant scientific literature and guideline referenced below, as well as the NY State instruction for this medical necessity review.

Yes, the requested health service/treatment of Psychological and Neuropsychological Test Administration was medically necessary for this patient.

The diagnostic interview and administered tests: grooved pegboard, Wisconsin Card Sorting, comprehensive trail making, medical symptom validity, Connor's performance and auditory evaluation, Rey complex figure test and recognition trial, and the Woodcock-Johnson test of cognitive abilities were reasonably provided with sound medical judgement. Testing, interpretation, and clinically appropriate follow up were provided to include follow up with the patient, review of records, follow up with the referring clinician and feedback sessions to the patient. These services were clinically appropriate and in the best interest of the patient, serving to provide more diagnostic clarity and recommendations to inform the referring clinician's selection of treatment, and to provide documentation to obtain reasonable accommodations with the patient's educational institution.

The psychological testing and psycho-diagnostic interview affirmed the patient's diagnoses of a depressive disorder and anxiety disorder, and also affirmed a diagnosis of post-traumatic stress disorder (PTSD) and ADHD (attention deficit hyperactivity disorder). Moreover, a thought disorder or other severe or persistent mental disorders were not identified with the testing.