Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for neuropsychological testing services provided for evaluation of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation provided, as well as the medical literature, there is support for a portion of the services at issue in this clinical setting. Per the records, the patient received the following neuropsychological testing: Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV); Woodcock Johnson Test of Academic Achievement, Fourth Edition (WJ-IV); Rorschach Inkblot Test (Rorschach); Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2); Million Clinical Multiaxial Inventory, Third Edition (MCMI-III); Substance Abuse Subtle Screening Inventory, Third Edition (SASSI-3); Autism Diagnostic Observation Schedule (ADOS); and Social Communication Questionnaire (SCQ). Both the WAIS-IV and the WJ-IV are used to evaluate intelligence and academic achievement. These two tests were not medically necessary for the evaluation of this patient. According to the records, the patient did well on the Scholastic Aptitude Test (SAT) and the American College Testing (ACT). She was accepted into the Johns Hopkins Center for the gifted and talented program. Any deficits in the academic achievement was primarily due to depression and anxiety. Therefore, both the WAIS-IV and the WJ-IV were not medically necessary for the evaluation of this patients intelligence and academic achievement as this was already known prior to the neuropsychological testing services. Additionally, the Rorschach Inkblot test, the MMPI-2, and the MCMI-III all test for personality disorders and assist in diagnosing diagnose other mental health conditions. Given the current documentation, a personality diagnosis was not under consideration. As such, the Rorschach Inkblot test, the MMPI-2, and the MCMI-III were not medically necessary for the evaluation of this patient. Other symptoms and diagnoses elicited in these tests could be achieved during a standard psychiatric evaluation. The SASSI-3 was also not medically necessary for this patient. This test is used to assess substance use disorders. While there was indication that this patient experimented with alcohol and marijuana, the records do not show she has a history of substance abuse or that she uses these substances with any regularity. With regard to SCQ and the ADOS, these portions of the neurological psychological testing were medically indicated. The records reflected a concern for autism spectrum disorder. If the patient was diagnosed with autism spectrum disorder, this diagnosis would change treatment decisions. Therefore, the SCQ and the ADOS were medically necessary to test for possible ASD.  The patients main symptoms were depression, anxiety, OCD, and ADHD. Therefore, ADOS and SCQ were medically necessary for the evaluation of this patient. However, WAIS-IV, WJ-IV, Rorschach, MMPI-2, MCMI-III, and the SASSI-3 were not medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.