Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized Anxiety Disorder, Social Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Major Depressive Disorder 

Treatment: neuropsychological testing

The insurer denied coverage for neuropsychological testing. The denial was upheld.

This patient is a female had neuropsychological testing to better assess attention, cognition, and learning issues. She had diagnoses of Generalized Anxiety Disorder, Social Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), and Major Depressive Disorder. She had difficulties with initiation, motivation, and organization. She had two leaves of absence from college due to anxiety and inability to manage her course work. She had pharmacotherapy and psychotherapy. She was taking Prozac and Wellbutrin. The patient had neuropsychological testing for clarity regarding potential cognitive, learning, and neurodevelopmental issues affecting academic settings. It substantiated the diagnosis of ADHD-combined type and also reported that anxiety was contributing to the difficulties. 

The insurer denied coverage for neuropsychological testing.

This reviewer agrees with the decision to deny coverage for neuropsychological testing. The American Academy of Child and Adolescent Psychiatry for Assessment and Treatment of Children and Adolescents and Adults with ADHD does not report that neuropsychological testing is required as part of the routine assessment of ADHD. It states that ADHD is a clinical diagnosis. It states that neuropsychological testing can be useful to evaluate specific deficits suggested by history, physical examination, or basic psychological testing, but are not sufficiently helpful for the diagnosis of ADHD to be performed routinely. A psychiatric, pediatric-medical, or neurological evaluation was considered to be appropriate to diagnosis ADHD.

The patient had reports of attention problems, difficulty with initiation, motivation, and organization and she already had a reported diagnosis of ADHD, in addition to Generalized Anxiety Disorder, Social Anxiety Disorder, and Major Depressive Disorder. She already was receiving pharmacotherapy to target anxiety and depressive symptoms, and also had reports of psychotherapy. She had reports of anxiety and depressive symptoms which contributed to her worsened functioning and the need to take leaves of absence at college, but she also was in treatment with pharmacotherapy, including taking two anti-anxiety antidepressant medications, as well as psychotherapy. The neuropsychological testing recommendations were for extended time, frequent breaks, requiring class notes and handouts, office hour meetings with professors, family, individual, group therapy, and pharmacotherapy. These recommendations are consistent with recommendations for ADHD when diagnosed clinically by a psychiatrist, neurologist, or medical provider. It is not considered standard to have neuropsychological testing in order to diagnosis ADHD, as this is a diagnosis of clinical assessment and also standard for recommendations for ADHD treatment, as this also is typically done clinically. Furthermore, she already had this diagnosis and was in treatment with a mental health provider for pharmacotherapy and psychotherapy.

This neuropsychological testing by this outpatient provider was not considered medically necessary for treatment or diagnosis for this patient for ADHD. The recommendations could have been provided by a clinical provider as well, and did not require neuropsychological testing.

Based on the above, the medical necessity for neuropsychological and psychological testing is not substantiated.  The insurer's denial is upheld.