*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + Medicare^SM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure

Neuropsychological Testing provides an objective, measurable assessment of brain function and cognitive abilities across key domains responsible for language, perception, memory, learning, problem solving, adaptation and constructional praxis. Testing may be indicated for an individual with a history of medical or neurological conditions that compromise cognitive or behavioral functioning, when there are reported concerns of impairment in cognitive functioning, or when it is necessary to differentiate between neurological diseases (e.g., dementia or brain injury) and psychiatric conditions (e.g., depression) when other diagnostic tools are inconclusive. Neuropsychological testing also assists in guiding treatment decisions and monitoring the effectiveness of interventions.

Policy Statement

Coverage will be provided for neuropsychological testing when it is determined to be medically necessary when the medical criteria and guidelines shown below are met.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefit determination. Coverage will be approved according to the EOC limitations if the criteria are met.

Coverage decisions will be made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) national coverage decisions;
• General coverage guidelines included in original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (E.O.C.), the E.O.C. always governs the determination of benefits.

Indications for Coverage

Psychological and Neuropsychological testing is considered reasonable and necessary when the following is met:

1. 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
2. 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
3. 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
4. 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 patient’s functional status; or
5. When there is a need to assess 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
6. 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
7. When there is a need for objective measurement of the patient’s 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 
8. When there is a need to establish a treatment plan by determining functional abilities/impairments in individuals with known or suspected CNS disorders; or
9. 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
10. 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 
11. 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
12. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders; or
13. When there is a need to diagnose cognitive or functional deficits in children and adolescents, it is 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.

When Coverage Wil Not be Approved

Psychological and Neuropsychological testing is considered not reasonable and necessary when:

1. The patient is not neurologically and cognitively able to participate in a meaningful way in the testing process, or 
2. Used as screening tests given to the individual or to general populations [Section1862(a)(7) of the Social Security Act does not extend coverage to screening procedures], or 
3. Administered for educational or vocational purposes that do not establish medical management, or 
4. Performed when abnormalities of brain function are not suspected, or 
5. Used for self-administered or self-scored inventories, or screening tests of cognitive function (whether paper-and-pencil or computerized), e.g., AIMS, Folstein Mini-Mental Status Examination, or 
6. Repeated when not required for medical decision-making (i.e., making a diagnosis or deciding whether to start or continue a particular rehabilitative or pharmacologic therapy), or 
7. Administered when the patient has a substance abuse background and any of the following apply:
   1. the patient has ongoing substance abuse such that test results would be inaccurate, or
   2. the patient is currently intoxicated, or
8. The patient has been diagnosed previously with brain dysfunction, such as Alzheimer’s diseases and there is no expectation that the testing would impact the patient's medical management, or 
9. For the g=following diagnosis alone without covered conditions:
   1. Headaches, including migraines
   2. History of myocardial infarction
   3. Intermittent explosive disorders
10. The test is administered solely as a screening test for Alzheimer's disease - Medicare does not cover screening for this diagnosis.

Billing/ Coding/Physician Documentation Information

This policy may apply to the following codes.  Inclusion of a code in the section does not guarantee reimbursement.  

Applicable codes: 96105, 96116, 96121, 96125, 96130-96133, 96136-96139, 96146

The Plan may request medical records for determination of medical necessity.  When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Related Policies

For Behavioral Health cases please refer to the Blue Cross NC Telehealth Medicare Reimbursement Policy (Telehealth | Providers | Blue Cross NC)

Special Notes

Examples of problems that might lead to neuropsychological testing include:

1. Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS dementia); 
2. Differential diagnosis between psychogenic and neurogenic syndromes; 
3. Delineation of the neurocognitive effects of CNS disorders; 
4. Neurocognitive monitoring of recovery or progression of CNS disorders; and/or 
5. Assessment of neurocognitive functions for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. 
6. Determining the management of the patient by confirmation or delineation of diagnosis.

Additional information regarding neuropsychological testing in regard to Behavioral Health and telehealth services please refer to Telehealth Reimbursement Policy via Telehealth | Providers | Blue Cross NC

References

1. Local Coverage Determination (LCD) Psychological and Neuropsychological Testing (L34646) effective 10/01/2015 accessed on 04/08/2026 via LCD - Psychological and Neuropsychological Testing (L34646)
   https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34646
2. Local Coverage Determination Article (LCA) Billing and Coding: Psychological and Neuropsychological Testing (A57481) effective date 10/31/2019 via Article - Billing and Coding: Psychological and Neuropsychological Testing (A57481)
   https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57481&ver=12&
3. Humana Medicare Advantage Medical Coverage Policy  - Psychological and Neuropsychological Testing effective date: 02/02/2026 accessed on 04/08/2026
4. Dean Health Plan by Medica – Neuropsychological Testing MP9493 effective date 01/01/202 accessed on 4/9/2026

Policy Implementation/Update Information

Revision Date: 04/16/2026: Newly created policy in the absence of a NCD, LCD in Palmetto Jurisdiction

 April 16, 2026: Medical Coverage Policy Committee

May 16, 2026: Physician Advisory Group Committee