Appeal type: unknown
Decision: unknown

 
Please note, the Local Coverage Determination (LCD), L34646, the Plan used in their decision to deny services 
is not binding in this case. The LCD does not have jurisdiction where the services will be provided. 
 
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 the neuropsychological testing is considered medically necessary for the following indications: 
 When there are 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 other disease 
processes; or 
 When neuropsychological data could provide clarification of clinical, laboratory, and neuroimaging 
data to assist in establishing a clinical diagnosis in neurological or systemic conditions known to affect 
CNS functioning; or 
 When there is a need to quantify cognitive or behavioral deficits related to CNS impairment, and the 
information will be useful in determining a prognosis or treatment planning by determining the rate of 
disease progression; or 
 When there is a need for a pre-surgical or treatment-related cognitive evaluation to inform 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) or 
significantly alter a patient's functional status; or 
 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), and this 
information is utilized in treatment planning; or 
 When there is a need to assess progression, recovery, and response to changing treatments, in patients 
with CNS disorders, in order to determine the most effective plan of care; or 
 When there is a need for objective measurement of patients' subjective complaints about memory, 
attention, or other cognitive dysfunction, which directly impacts medical management by differentiating 
psychogenic from neurogenic syndromes (e.g., dementia vs. depression), and in some cases will result 
in initial detection of neurological disorders or systemic diseases affecting the brain; or 
 When there is a need for treatment planning purposes of determining functional abilities/impairments in 
individuals with known or suspected CNS disorders (e.g., capacity for independent living or movement 
from a family home into an institutional setting); or  When there is a need to determine whether a patient can comprehend and participate effectively in 
complex treatment regimens and to determine functional capacity for health care decision-making, 
independent living, etc.; or 
 When there is a need to design, administer, and/or assess outcomes of cognitive rehabilitation 
procedures, often in collaboration with other specialists such as speech pathologists, occupational 
therapists, physiatrists, and rehabilitation psychologists; or 
 When there is a need for treatment planning of identification and assessment of neurocognitive sequelae 
of disease ; or 
 Assessment of neurocognitive functions for the formulation of rehabilitation and/or management 
strategies for certain individuals with neuropsychiatric disorders; or 
 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 the Local Coverage Determination for Psychological and Neuropsychological Tests, 
L34520.  
 
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.