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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 state that 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 patients 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 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. 
You can find this information in Local Coverage Determination (LCD): Psychological and Neurological 
Testing (L34646). 
 
The rules say that testing typically requires four to eight hours to perform, including administration 
and scoring. If the testing is performed over several days, the time for all testing should be combined and 
reported on the last day of service. Psychological and Neuropsychological testing is medically necessary for 
multiple reasons. The medical record must document the reason the tests are being performed. You can find 
this information in Local Coverage Article: Billing and Coding: Psychological and Neuropsychological Testing 
(A57481). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.