Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Psychological tests are tests administered to assist with the diagnosis or treatment of a mental or emotional illness. They are most frequently administered by a psychologist.

2)    All Psychological tests require preauthorization.

3)     The number of hours or units requested for testing should not exceed the reasonable time necessary to address the clinical questions with the identified measures. Usual testing time is four (4) to six (6) hours to perform (including administration, scoring, and interpretation.) For more than 6 hours of testing, medical necessity for the extended testing should be documented. Extended testing for more than 8 hours is not covered.

4)    Use of Telemedicine services for providing Psychological testing is not covered.

1)    The following criteria must be met for coverage: 

a)    Baseline studies will not be approved.

b)    The request should include documentation of a psychological/psychiatric evaluation recommending the testing. 

i)     The clinical information provided should document the patient’s degree of functional impairment.

ii)    The medical record must indicate the presence of mental illness ,signs of mental illness or a change in mental status for which psychological testing is indicated

iii)     There should be a significant change (e.g. unable to work or go to school) in the patient’s condition as indicated by the attending physician. If there is no significant change, testing will not be approved.

iv)     Adjustment reactions or dysphoria associated with moving to a new environment do not constitute medical necessity for testing.

v)    There should be evidence to support the following contentions:

(1)  A clinical interview will not suffice for assessment; AND

(2)  The testing is necessary to make or document a new diagnosis; OR

(3)  The testing is needed to support changes in therapeutic measures Results of proposed psychological testing are judged likely to affect care or treatment of patient (e.g., contribute substantially to decision of need for, or modification to, rehabilitative or habilitative needs or treatment plan).

vi)     Symptoms, behaviors, or functional impairments related to underlying behavioral health disorder have been identified as appropriate for evaluation by psychological testing.

vii)     Psychological testing can be billed by psychologists and psychiatrists only.

viii)    Patient is able to participate as needed such that proposed testing is likely to be feasible (e.g., mental status, intellectual or cognitive abilities, language skills, or developmental level are appropriate to proposed testing).

ix)     Patient is not engaged in active substance use, in withdrawal, or in recovery from recent chronic substance use.

x)    Medical, neurologic, mental status, and psychiatric exams have been done as indicated.

xi)     Diagnostic testing has been done as indicated (e.g., CT scan, MRI), when appropriate.

xii)     Recommended testing is necessary and information achieved by psychological testing is not attainable through routine medical, neurologic, or psychological assessment. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g. failed medication management) do not generally require psychological testing; in this situation, consultation with a psychiatric medical director will be required for approval.

c)    The request should indicate the exact nature of the service requested – test names. 

i)     Each test performed must be medically necessary and therefore, standardized batteries of tests are not acceptable.

d)    The AIMS, Folstein mini-mental exam (or similar tests) are not separately reimbursable and are included in the clinical interview or evaluation and management service.

e)    Appropriate testing for mental retardation and autism may be authorized.  Specific tests may include Psych Educational Profile (PEP), Childhood Autism Rating Scale (CARS), Gilliam Autism Rating Scale (GARS), or Vinclains. Direct testing of patient as parent rating scale is frequently used and would be approved. This applies only to children ages 0-6 years of age.

f)     Psychological tests are not psychotherapeutic modalities, but are diagnostic aids.  Use of such tests when mental illness is not suspected would be a screening procedure and, as such, is not covered.

g)    Repeat testing is generally not required for an established diagnosis and generally will not be approved in that circumstance.

2)    Neuropsychological testing is covered in another policy (See BI005).

3)    As with all criteria/policies, if there is an inability to determine appropriateness, requests for psychological testing will be referred to the Medical Director for review.

Codes Used In This BI:

1)    Psychological testing requires pre-authorization unless being included as part of an inpatient admission.

2)    Psychological testing for dementia screening and substance misuse is not covered. Non-specific behaviors that do not suggest the possibility of mental illness or disability are not an acceptable indication for testing.

3)    Psychological testing is subject to the limits of the contract certificate coverage limitations.

4)    Exclusions include educational testing, court ordered testing (unless medically necessary), and any non-medical use, such as connected to employment, applications, legal, etc.

5)    Interpretation of results to family members, is considered incidental to psychiatric treatment and is not covered.

1)    Medicare Provider’ News, September 1, 1995, Psychological Testing, pages 10-11.  Policy effective August 30, 1995.

2)    MCG Psychological Testing ORG: B-807-T (BHG)

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail.  State and federal mandates will be followed as they apply.