Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Attention Deficit Hyperactivity Disorder.
Treatment:  Psychological testing evaluation services (codes 96130, 96131).

The insurer denied coverage for psychological testing evaluation services (codes 96130, 96131).  The denial is upheld.

This adult female reportedly had psychological testing done to better clarify diagnoses including Attention Deficit Hyperactivity Disorder (ADHD), Post Traumatic Stress Disorder (PTSD), and Mood Disorder, as there was concern that she may have bipolar disorder due to vacillating mood. She reportedly had concentration and attention issues, and there was suspicion of ADHD diagnosis. She also reportedly had abuse victimization and there was suspicion of PTSD diagnosis. She reportedly was in outpatient mental health treatment for counseling and also for pharmacotherapy and had taken Concerta for attention issues and Lexapro for anxiety and mood symptoms, but it was discontinued. The psychological testing revealed diagnoses of Major Depressive Disorder, PTSD, and ADHD and recommendations were for Eye Movement Desensitization and Reprocessing (EMDR) for PTSD and psychotherapy for depression with goals to improve self-esteem, motivation to change, build healthy coping skills and effective communication. 

The medical records provided did not provide specific evidence that this psychological testing was medically necessary for diagnostic clarification or that she was referred for testing by a licensed mental health professional or that the patient is being actively treated by a mental health professional.

InterQual Adult-Psychological Testing criteria reports that testing needs to be administered by a licensed psychologist or other qualified mental health provider, needs to be standardized, have normative data, and the purpose must be to answer a specific question that can't be answered by one or more comprehensive evaluations or consultations with the patient, family, other supports, or other treating providers. It also states that a battery of tests must answer specific diagnostic/clinical questions, that they must have the cognitive ability, and that this testing must be reasonably expected to contribute significantly in the development and implementation of individualized treatment plans. In this case, it is not considered standard for the use of psychological testing for differential diagnosis of Mood disorder, PTSD, or ADHD. It is considered standard for these diagnoses to be done by clinical assessment by mental health professionals and not psychological testing. Psychological testing is not generally considered medically necessary treatment for diagnosis or diagnostic clarification of common mental disorders in the absence of severe symptoms, psychosis, or complicating factors that may confuse a clinical picture. The standard way of diagnosing mood disorder, PTSD, or ADHD is by clinical assessment and not psychological testing. 

There was no specific reported evidence to support the need for psychological testing, and there was no documentation that she was referred for testing by a licensed mental health professional or that the patient is being actively treated by a mental health professional, which were criteria for psychological testing by the insurer. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for psychological testing evaluation services (codes 96130, 96131) is not substantiated.