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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Neuropsychological assessment is considered medically necessary for the following 
indications: 
1. When there are mild or questionable deficits on standard mental status testing or clinical interview, and 
a neuropsychological assessment is needed to establish the presence of abnormalities or distinguish 
them from changes that may occur with normal aging, or the expected progression of other disease 
processes; or 
2. When neuropsychological data can be combined with clinical, laboratory, and neuroimaging data to 
assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect CNS 
functioning; or 
3. When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, especially 
when the information will be useful in determining a prognosis or informing treatment planning by 
determining the rate of disease progression; or 
4. When there is a need for a pre-surgical or treatment-related cognitive evaluation to determine whether 
one might safely proceed with a medical or surgical procedure that may affect brain function (e.g., deep 
brain stimulation, resection of brain tumors or arteriovenous malformations, epilepsy surgery, stem cell 
transplant) or significantly alter a patients functional status; or 
5. When there is a need to assess the potential impact of adverse effects of therapeutic substances that may 
cause cognitive impairment (e.g., radiation, chemotherapy, antiepileptic medications), especially when 
this information is utilized to determine treatment planning; or 
6. When there is a need to monitor progression, recovery, and response to changing treatments, in patients 
with CNS disorders, in order to establish the most effective plan of care; or 
7. When there is a need for objective measurement of the patients subjective complaints about memory, 
attention, or other cognitive dysfunction, which serves to determine treatment by differentiating 
psychogenic from neurogenic syndromes (e.g., dementia vs. depression); or 
8. When there is a need to establish a treatment plan by determining functional abilities/impairments in 
individuals with known or suspected CNS disorders; or 
9. When there is a need to determine whether a patient can comprehend and participate effectively in 
complex treatment regimens (e.g., surgeries to modify facial appearance, hearing, or tongue debulking 
in craniofacial or Down syndrome patients; transplant or bariatric surgeries in patients with diminished 
capacity), and to determine functional capacity for health care decision-making, work, independent 
living, managing financial affairs, etc.; or 
10. When there is a need to design, administer, and/or monitor outcomes of cognitive rehabilitation 
procedures, such as compensatory memory training for brain-injured patients; or 
11. When there is a need to establish treatment planning through identification and assessment of the 
neurocognitive sequelae of systemic disease (e.g., hepatic encephalopathy; anoxic/hypoxic injury 
associated with cardiac procedures); or 
12. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders; or 
13. When there is a need to diagnose cognitive or functional deficits in children and adolescents based on 
an inability to develop expected knowledge, skills or abilities as required to adapt to new or changing 
cognitive, social, emotional, or physical demands. 
 
Limitations of Coverage: 
Psychological and Neuropsychological testing is not considered reasonable and necessary when: 
1. The patient is not neurologically and cognitively able to participate in a meaningful way in the testing 
process, or  
2. Used as screening tests given to the individual or to general populations [Section 1862(a)(7) of the 
Social Security Act does not extend coverage to screening procedures], or  
3. Administered for educational or vocational purposes that do not establish medical management, or  
4. Performed when abnormalities of brain function are not suspected, or  
5. Used for self-administered or self-scored inventories, or screening tests of cognitive function (whether 
paper-and-pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination, or  
6. Repeated when not required for medical decision-making (i.e., making a diagnosis or deciding whether 
to start or continue a particular rehabilitative or pharmacologic therapy), or  
7. Administered when the patient has a substance abuse background and any of the following apply:  
o a. the patient has ongoing substance abuse such that test results would be inaccurate, or 
o b. the patient is currently intoxicated, or 
8. The patient has been diagnosed previously with brain dysfunction, such as Alzheimers diseases and 
there is no expectation that the testing would impact the patient's medical management.  
9. The test is being given solely as a screening test for Alzheimer's disease - Medicare does not cover this 
screening for this diagnosis. 
You can find this rule in the Local Coverage Determination (LCD): Psychological and Neuropsychological 
Testing (L34646) effective October 31, 2019. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.