Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety.
Treatment: Outpatient Psychological Testing Services.

The insurer denied: Outpatient Psychological Testing Services.  The denial is overturned.

The patient is a teenage male. He was referred for psychological/neuropsychological testing to address diagnostic considerations and treatment issues in a case with a diagnosis of an unspecified anxiety disorder and a provisional diagnosis of attention-deficit/hyperactivity disorder-inattentive type. The patient has paroxysmal dyspneic episodes with lightheadedness, nausea, visual problems, headache, and panic attacks, as well as persistent problems with attention, concentration, and focus causing continued functional impairment with regard to social, educational, and daily functioning. There were no acute general medical issues and no substance use disorders in this case. The evaluation and clinical interview of 4 months ago summarizes appropriate laboratory testing and results of electroencephalogram (EEG), visual evoked potentials with visual stimulations, and magnetic resonance imaging (MRI) of the brain, and the plan for neuropsychological testing in order to affirm the provisional diagnosis and identify underlying diagnostic problems. The purpose of the testing is to better inform treatment, as well as provide diagnostic clarity. The health plan has denied coverage for the psychological/neuropsychological testing services based on medical necessity and InterQual Criteria pertaining to neuropsychological and developmental testing. The denial determination indicates that approval must include evidence of a clinical interview, a thinking problem, and justification for time requested for testing, as well as the impact on treatment and outcome of treatment. The appeal asserts that the patient meets plan criteria for psychological testing services including the request for 10 hours of services that is noted to be within the standard of care and clinical guidelines. The appeal indicates that testing will inform treatment of attention-deficit/hyperactivity disorder and other identified problems. Testing is viewed as imperative in this case scenario and will serve to affirm diagnoses. The appeal argues that a delay in testing services would be detrimental to the patient who has impaired functioning with home, school, and community activities.

The Outpatient Psychological Testing Services are medically necessary.

The requested services are in keeping with prevailing standards of clinical practice and consistent with published guidelines and the scientific literature. Moreover, the requested services/treatment being provided in this case are clinically appropriate and are backed by credible scientific evidence known to benefit patients with the conditions diagnosed in this case. Indeed, the psycho-diagnostic interview and psychological testing, as well as other services that include follow-up with the patient and patient's parents did serve to clarify the patient's diagnoses and inform treatment with respect to the selection and use of clinically appropriate therapeutic interventions known to benefit patients with attention-deficit/hyperactivity disorder and anxiety disorder, and the testing ruled out other mental disorders. The psycho-diagnostic interview and psychological testing, as well as other services that include follow-up with the patient and patient's parents are requested with sound medical judgment in the best interest of the patient. Thus, the entire time spent to provide Psychological Testing Mental Health Services should be covered under the plan with revenue codes, as requested and indicated.