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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 testing is requested for patients with a history of psychological,
neurologic or medical disorders known to impact cognitive or neurobehavioral functioning.
Neuropsychological testing 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
neuropsychological testing 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 testing 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 patient's functional status; or
5. When there is a need to test for 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 patient's 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.
You can find this rule in Local Coverage Determination (LCD): Psychological and Neuropsychological Testing
(L34646) - Effective October 1, 2020.
The rules say that examples of problems that might lead to neuropsychological testing include:
1. Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head
injury, anoxic injuries, AIDS dementia);
2. Differential diagnosis between psychogenic and neurogenic syndromes;
3. Delineation of the neurocognitive effects of CNS disorders;
4. Neurocognitive monitoring of recovery or progression of CNS disorders; and/or
5. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies
among individuals with neuropsychiatric disorders.
6. Determining the management of the patient by confirmation or delineation of diagnosis.
You can find this rule in Local Coverage Determination (LCD): Psychological and Neuropsychological Testing
(L34646) - Effective October 1, 2020.
The rules say that that neuropsychological testing is considered not 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:
a. the patient has ongoing substance abuse such that test results would be inaccurate, or
b. the patient is currently intoxicated
8. The patient has been diagnosed previously with brain dysfunction, such as Alzheimer's diseases and there is
no expectation that the testing would impact the patient's medical management, or
9. The test is administered solely as a screening test for Alzheimer's disease - Medicare does not cover
screening for this diagnosis.
You can find this rule in Local Coverage Determination (LCD): Psychological and Neuropsychological Testing
(L34646) - Effective October 1, 2020.
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.