Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive changes

Treatment: (96132 x 1, 96133 x 7) neuropsychological testing

The insurer denied coverage for (96132 x 1, 96133 x 7) neuropsychological testing

The denial is modified


The patient is an adult male who experienced a significant shoulder injury while on the job in 2021. The patient has been experiencing cognitive changes and has been having increasing difficulty with activities of daily living. 

The provider who referred the patient for neuropsychological evaluation did not clearly spell out the purpose of neuropsychological testing. The reason that neuropsychological testing was being requested at a particular point in time and did not specifically indicate (beyond "to see what is going on") the purpose of neuropsychological testing in terms of treatment planning. 

However, some next-step assessment is indicated, and referral for neuropsychological consultation is appropriate and will reasonably be useful in terms of determining the patient's safety for driving and independent living, for determining the role of alcohol abuse or concussion or possible early onset memory disorder, and for the purpose of directing treatment planning as well as practical supports.      

There are no contemporaneous records of evaluation or treatment of the work injury provided. The records indicate that the patient was struck on the left side of his body with no reported loss of consciousness, but recalls being shocked at the time of the injury. The patient's subsequent presentation has been described as meeting criteria for mild traumatic brain injury or post concussive disorder, and he has had rehabilitation therapies. 

A review of the medical records in chronological fashion does suggest decline in functioning. A physical medicine and rehabilitation consultation noted a Saint Louis University Mental Status (SLUMS) score of eight; this is a remarkably poor performance and, in combination with apparent functional decline, does warrant follow up to clarify the type and severity of cognitive impairment and to direct treatment and support. Further evaluation is warranted here, and there is reason to suspect some cognitive decline over and above what might be attributed to a concussion two years previously. 

Records indicate for example there had been a period of alcohol abuse, which may be contributing. A brief neuropsychological evaluation may help clarify cognitive and emotional functioning and determine what next-step referrals would be appropriate - for example neurology consultation - and may help determine what community resources may be indicated and provide the patient's medical providers information regarding recommendations around safety while driving or capacity to live independently. 

For the clinical purposes supported in these brief records, it is reasonable to partially approve (96132 x 1, 96133 x 4) neuropsychological testing.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for neuropsychological testing services is modified to (96132 x 1, 96133 x 4).