Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental Delays

Treatment: Psychological Testing Services

The insurer denied coverage for psychological testing services

The denial is overturned

This child reportedly had developmental delays, exposure to childhood trauma including abuse and neglect, alcohol and drug related exposure in utero with reported neurodevelopmental delays, behavioral symptoms including aggression, property destruction, impulsivity, severe hyperactivity, attention problems and distractibility thought to be related to alcohol and substance exposure in utero, social participation issues, atypical social functioning, poor eye contact, preoccupation with video games, visual motor, motor, speech/language delays, and hearing issues. He reportedly throws himself on the ground at times and elopes. It was reported that he had past suicidal ideation at school. He reportedly had diagnoses of Post-Traumatic Stress Disorder (PTSD), Oppositional Defiant Disorder, Reactive Attachment Disorder, Alcohol Related Neurodevelopmental Disorder, and Sensory Integration Disorder. He lived with his maternal grandparents. He reportedly was attending kindergarten in an 8:1:1 classroom with an Individual Education Plan (IEP). 
  
The medical records provided sufficient specific evidence to support that he required neuropsychological testing. 

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. Neuropsychological testing can be useful to evaluate specific deficits suggested by history, physical examination, or basic psychological testing. It can also measure cognitive ability and adaptive skills indicated for further treatment planning, clarify areas of strength and weakness useful in designing intervention programs. It could reflect accurate assessment of strength and vulnerabilities with explicit description of services to be provided including goals and objectives, and procedures for monitoring effectiveness, and in quantifying deficits in social communication and interaction as well as restricted repetitive and stereotypic behaviors, interests, or activities, as well as intellectual and adaptive functioning. 

The request for the neuropsychological testing was for better assessment of neurocognitive functioning and diagnostic clarifications. 

It is considered standard to use neuropsychological testing to help assist in assessing specific deficit areas in social communication and interaction as well as restricted repetitive and stereotypic behaviors, interests, or activities. This was a complex child with significant exposures with trauma and drug and alcohol exposure in utero who had multiple neurodevelopmental delays and issues and executive functioning issues so he required neuropsychological testing to assess neurocognitive functioning for diagnostic clarification secondary to prenatal exposure to drugs and alcohol and due to childhood trauma, and to assess significant executive functional impairments, social functioning, attention issues, sensory motor delays, and speech language delays. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the psychological testing services is overturned. Medical Necessity is substantiated.