Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)

Treatment psychological testing

The insurer denied coverage for psychological testing.

The denial is overturned.

This patient was referred to psychological testing to determine the nature of his difficulties with attention and focusing and to rule out attention deficit hyperactivity disorder (ADHD) diagnosis as a cause of this and also to assess how his TBI (traumatic brain injury) was contributing to symptoms. He reportedly had a diagnosis of Major Depressive Disorder-recurrent-in partial remission. He reportedly lived with his wife. He reportedly had taken Bupropion and Trazodone. He reportedly had psychological testing on numerous dates of service. He reported that there was a severe lack of psychological testing providers by the insurer.
  
Psychological testing was considered medically necessary to assist in determining the nature of his difficulties with attention and focusing and to rule out ADHD diagnosis as a cause of this and also to assess how his TBI (traumatic brain injury) was contributing to symptoms. According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders although the standard diagnostic work up is a psychiatric evaluation and assessment including mental status, history of present illness, a past psychiatric history, a medical work up to rule out possible medical causes of mood symptoms, family assessment, and the recommended treatments are pharmacotherapy to target mood symptoms as well as psychosocial interventions, cognitive behavioral therapy, interpersonal therapy, or psychotherapy, it also states that if a provider needs additional information to assist in assessing intellectual or cognitive functioning or to assess for possible neurological deficits, neuropsychological tests can be performed by a psychologist. This was the case with this patient.  Also, in trying to diagnosis ADHD psychological testing is indicated if there is a strong indication that useful information from testing would impact the patient's care and treatment or make a diagnosis that a provider is unable to make by other methods such as a psychiatric evaluation. This also was the case with this patient. 

The American Academy of Clinical Neuropsychology (AACN) Practice Guidelines for Neuropsychological Assessment and Consultation reports that neuropsychological evaluations vary in content depending on their purpose but they typically assess multiple neurocognitive and emotional functions. Primary cognitive domains tested include: intellectual functions; academic skills, receptive and expressive language skills, simple and complex attention; learning and memory, visuospatial abilities, executive functions, problem solving and reasoning abilities, and sensorimotor skills. In this case this patient had difficulties with attention and focus and reportedly had a past TBI and testing was considered appropriate to assess the nature of the attention problems. According to the psychological testing, it did not support the diagnosis of ADHD and reported that he had normal intelligence, but it was determined that attention difficulties were most likely related to depression and anxiety. It was reported that his inattention did not appear to be related to overall intellectual functioning, academic achievement, memory deficits, ADHD symptoms or deficits but rather due to depression and anxiety. This helped the provider in the psychiatric treatment plan as pharmacotherapy changes targeting depression and anxiety and cognitive behavioral therapy were considered the treatment of choice, and this was aided by this psychological testing. Furthermore, TBI's typically contribute to cognitive and psychiatric symptoms, and psychological testing can assist in determining if current symptoms are more a result of TBI verses other psychiatric disorders.  It was reported that there was a severe lack of psychological testing providers in network. This psychological testing was considered medically necessary and appropriate for assisting this patient's providers in his psychiatric treatment plan and was considered standard assessment. 

Psychological testing on multiple dates. It did not appear that the insurer acted in the best interests of the patient then.

Based on the above, the medical necessity for the psychological testing provided is substantiated. The insurer's denial is overturned.