Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive deficits in memory and language
Treatment: Neuropsychological testing
The insurer denied coverage for: Neuropsychological testing
The denial is: Overturned  
This adult patient had persistent memory and language issues including difficulty with word finding and expressive language to the point of saying the wrong words or being mute. The patient reportedly had neurological issues including migraines, seizure history, past cerebral vascular accident (CVA), tremors, and fell due to right sided weakness in the past and had visual field deficits. It was reported that their neurologist recommended neuropsychological testing to assess the patient's cognitive deficits including memory and language. The patient reportedly was taking Depakote, baby Aspirin, and Eliquis.
  
This reviewer disagrees with the decision to deny coverage for neuropsychological testing as the medical records for review provided enough specific evidence to support that the patient required this level of care. This patient had active cognitive deficits of memory and language issues including difficulty with word finding and expressive language to the point of saying the wrong words or being mute, so the neurologist recommended neuropsychological testing to better assess the patient's cognitive deficits. 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 also 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. 

In this case, it was reported that this patient had cognitive deficits in memory and language including word finding, expressive language and using wrong words to communicate or no words, so this was interfering with the patient's functioning and required a more specific assessment with neuropsychological testing to better assess the patient's deficits. The patient also had a history of depression. The request for the neuropsychological testing was for better assessment of neurocognitive functioning. Also, this testing was considered to be medically necessary to assess diagnostic clarification and possible etiology to his memory and language deficits. Neuropsychological testing was considered standard and appropriate diagnostic testing for this patient. It is considered standard to use neuropsychological testing to help assist in assessing specific deficit areas in cognition including memory and language deficits. The patient's deficits were reportedly interfering with his functioning as well. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for outpatient - procedures, neuropsychological testing, 8 procedures, requested is substantiated.