Appeal type: unknown
Decision: unknown

 
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: 
 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    When there is a need to establish a treatment plan by determining functional abilities/impairments in 
individuals with known or suspected CNS disorders; or 
    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     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 
    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 
    Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies 
among 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 information in the Local Coverage Determination (LCD) Psychological and 
Neuropsychological Testing L34646. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.