Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the computerized dynamic posturography sensory organization test (92548), neuropsychological testing evaluation services (96132), psychological or neuropsychological test administration and scoring (96138) and annual alcohol misuse screening (G0442). We decided that the Plan does not have to pay for computerized dynamic posturography sensory organization test (92548).

You asked the Plan to pay for the computerized dynamic posturography sensory organization test (92548), neuropsychological testing evaluation services (96132), psychological or neuropsychological test administration and scoring (96138) and annual alcohol misuse screening (G0442). You say that you would like reconsideration because these services are payable on the same day as the approved code for the annual wellness visit. The Plan says that the clinical value and effectiveness of computerized dynamic posturography sensory organization test in the setting of preventative screening have not been demonstrated in the peer-reviewed literature.

We decided that the Plan has to pay for neuropsychological testing evaluation services (96132), psychological or neuropsychological test administration and scoring (96138) and annual alcohol misuse screening (G0442).

The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the neuropsychological testing evaluation services (96132), psychological or neuropsychological test administration and scoring (96138) and annual alcohol misuse screening (G0442) have been met. Specifically, the Plan is denying these services based on NCCI edits. There are no NCCI edits for the codes at issue indicating that no modifier would be necessary to show that these services are separately payable. It is the burden of the Health Plan to substantiate their decision with evidence. This denial has not been substantiated; therefore, we must find in your favor. We decided that the Plan has to pay for neuropsychological testing evaluation services (96132), psychological or neuropsychological test administration and scoring (96138) and annual alcohol misuse screening (G0442).

We also decided that the Plan does not have to pay for computerized dynamic posturography sensory organization test (92548).

The Plan follows Medicare rules. Medicare rules say that services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for computerized dynamic posturography sensory organization test (92548). Our reviewer says that within published peer-reviewed medical literature there have not been any well-designed studies conducted to validate the results of the preliminary studies. Furthermore, the data from published studies have failed to demonstrate any beneficial effects of computerized dynamic posturography evaluation on patient outcomes and management. Our physician reviewer found computerized dynamic posturography is not medically reasonable and necessary in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of computerized dynamic posturography sensory organization test (92548) have not been met. Therefore, we decided that the Plan does not have to pay for computerized dynamic posturography sensory organization test (92548).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.