NEUROPSYCHOLOGICAL TESTING

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                            NEUROPSYCHOLOGICAL TESTING
Protocol: NEU032
Effective Date: January 17, 2011

Table of Contents                                                                                                                             Page

COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE......................................... 1
BACKGROUND ...................................................................................................................................... 3
CLINICAL EVIDENCE........................................................................................................................... 4
APPLICABLE CODES .......................................................................................................................... 18
REFERENCES ....................................................................................................................................... 19
PROTOCOL HISTORY/REVISION INFORMATION ........................................................................ 27

INSTRUCTIONS FOR USE
This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding
coverage, the enrollee specific document must be referenced. The terms of an enrollee's document
(e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event
of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first
identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage
prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may
apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and
Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute
medical advice.


COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE

Neuropsychological testing is medically necessary for the evaluation of patients with the
following conditions when the result of testing will influence diagnosis, treatment, discharge,
and/or level of care planning:

1. Attention deficit hyperactivity disorder (ADHD) when all of the following are present:
   • Specific neurocognitive behavioral deficits related to ADHD need to be evaluated, and
   • Testing has been recommended by a physician and is related or secondary to a known or
      suspected organic-medical condition resulting from brain injury or disease process (e.g., repeat
      concussion, intractable seizure disorder, cancer treatment effects, genetic disorders, inborn
      errors of metabolism), and
   • Neuropsychological testing is necessary for clinical decision making
   The scope of these criteria is applicable only to neuropsychological testing that is covered by the
   medical benefit. These criteria do not apply to evaluate or determine educational interventions.

2. Confirmed brain lesion including the following:
   • Brain abscess
   • Cranial or brain tumors


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3. Dementia, or symptoms of dementia such as memory impairment or memory loss (including
   extrapyramidal disorders such as Parkinson's disease) when all of the following are present:
   • Dementia or symptoms of dementia are associated with a new onset or progressive memory
       loss and at least one of the following cognitive disturbances: aphasia, apraxia, agnosia, or a
       disturbance or change in executive functioning (DSM-IV-TR), and
   • Neuropsychological testing is necessary for clinical decision making

4. Demyelinating disorders including multiple sclerosis

5. Developmental disorders or significant developmental delays when all of the following are present:
   • The developmental disorder or delay is associated with a known or suspected medical cause
      (e.g., traumatic brain injury, in utero toxin exposure, early seizure disorder, sickle cell disease),
      and
   • The developmental disorder or delay involves impairment in two or more areas of development
      including reciprocal social interaction skills, communication skills, speech/language skills,
      motor skills, attention, executive function, or memory (DSM-IV-TR)
   The scope of these criteria is applicable only to neuropsychological testing that is covered by the
   medical benefit. These criteria do not apply to evaluate or determine educational interventions.

6. Encephalopathy including acquired immunodeficiency syndrome (AIDS) encephalopathy, human
   immunodeficiency virus (HIV) encephalopathy, hepatic encephalopathy, Lyme disease
   encephalopathy including neuroborreliosis, Wernicke's encephalopathy and systemic lupus
   erythematosus (SLE).

7. Neurotoxin exposure with at least one of the following:
   • Demonstrated serum levels of neurotoxins
   • Individual with documented significant prenatal alcohol, drug, or toxin exposure

8. Seizure disorder including patients with epilepsy and patients being considered for epilepsy surgery

9. Stroke or more than one transient ischemic attack

10. Traumatic brain injury (TBI): TBI is defined as physical damage or destruction of brain tissue that
    includes both closed and penetrating injuries. (Centers for Disease Control and Prevention).

Neuropsychological testing is not medically necessary for the following diagnoses alone without
other medically necessary behavioral conditions as noted above:
    • Migraine headache
    • History of myocardial infarction
    • Intermittent explosive disorder
There is insufficient clinical evidence to demonstrate that the use of neuropsychological testing for
patients with myocardial infarction, migraine headaches or intermittent explosive disorder without
associated cognitive disorders can be used effectively for clinical decision making to improve patient
management of those conditions. Refer to United Behavioral Health Neuropsychological Testing



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Guidelines and companion Operational Guide for more information regarding neuropsychological
testing.


Medicare does not have a National Coverage Determination or a Local Coverage Determination for
Nevada for Neuropsychological Testing.

Medicare covers neuropsychological testing when criteria are met. For Medicare's billing and coding
guidelines, refer to the Medicare Benefit Policy Manual Chapter 15, Section 80.2 Psychological Tests
and Neuropsychological Tests at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

For Medicare and Medicaid Determinations Related to States Outside of Nevada:
Please review Local Coverage Determinations that apply to other states outside of Nevada.
http://www.cms.hhs.gov/mcd/search

Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage
database on the Centers for Medicare and Medicaid Services’ Website.


BACKGROUND

Neuropsychological testing applies standardized behavioral measures to evaluate skills and abilities
that correlate with brain functioning. Neuropsychological testing specifically provides information
relevant to the determination of the presence of neurological damage or dysfunction and associated
functional deficits. Neuropsychological testing is customarily associated with neurological diagnoses
rather than behavioral health diagnoses.

Neuropsychological testing involves the use of a standard fixed or individualized/flexible battery of
tests that focuses on cognitive functions specific to a patient's reported problems. Comparison
standards for deficit measurement can be normative or individualized. Measurement of deficits cannot
be based on single test results and should always be assessed in the context of the medical and
neurological examination. The precise descriptive information obtained from testing can provide
information about the cognitive capabilities and limitations of the patient, as well as psychological and
behavioral problems which may adversely impact cognition.. When indicated, follow-up testing can
document deterioration or progression of particular conditions and evaluate benefits or lack thereof of
treatment interventions.

Neuropsychological tests are administered in a variety of contexts including computers and visual
aides. Following an initial clinical interview with a neuropsychologist, tests are strategically selected to
identify specific deficits and preserved abilities. Standardized tests are then administered by a trained
technician or neuropsychologist. Some tests offer multiple forms making them useful for repeated
administration to the same patient, thereby minimizing practice effects. In light of the numerous
procedures available for assessment of different neurocognitive functions, test selection is based on
familiarity of the examiner with certain tests, availability of appropriate normative data, ability of the
patient to participate in testing (e.g., quadriplegic or hemiplegic patients may not be able to participate
in psychomotor testing), and validity of particular procedures for the specific function being measured.



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For developmental disorders, neuropsychological tests are useful as part of a complete clinical decision
making process and do not unilaterally make the diagnosis of autism spectrum disorder
(Zwaigenbaum, 2009).

Neuropsychological tests include but are not limited to the following: Boston Diagnostic Aphasia
Examination (BDAE), Conners' Continuous Performance Test (CCPT), Controlled Oral Word
Association Test (COWAT), Delis-Kaplan Test Battery, Freedom from Distractibility Index (FFDI)
from the Wechsler Intelligence Scales, Gordon Diagnostic System (GDS), Halstead-Reitan
Neuropsychological Battery, Rey Auditory Verbal Learning Test (RAVLT), Rey-Osterreith Complex
Figure Test, Stroop Color and Word Test, Test of Variables of Attention (TOVA), Trail Making Tests,
Wechsler Adult Intelligence Scale-Revised (WAIS-III/IV), Wide Range Assessment of Memory and
Learning (WRAML), and Wisconsin Card Sorting Test (WCST). At times, neurocognitive measures
are supplemented by emotional functioning and personality testing and include but are not limited to
the following: Minnesota Multiphasic Personality Inventory-2 (MMPI-2)/Minnesota Multiphasic
Personality Inventory-A (MMPI-A), Personality Assessment Inventory (PAI), Geriatric Rating Scale,
Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Rorschach Inkblot Method.

Neuropsychological testing is conducted or supervised by an independently licensed psychologist
neuro-behavioral psychiatrist, developmental pediatrician, or developmental/behavioral pediatrician
with training and expertise in the types of tests/assessment being requested and can perform them at a
level proficient to interpret testing data in accordance with the American Psychological Association
standards of practice and/or in accordance with the relevant national professional and ethical standard
observed under one’s state licensure to conduct or supervise neuropsychological testing service
(Ethical Principles of Psychologists and Code of Conduct). (United Behavioral Health. 2010
Operational Guide to Psychological and Neuropsychological
Testing)


CLINICAL EVIDENCE

Attention Deficit Hyperactivity Disorder (ADHD)
According to Hayes, overall, positive predictive power (PPP), or the percentage of patients with
impaired scores being diagnosed with ADHD by standard criteria, was moderate to good for
neuropsychological tests measuring attention, vigilance, response inhibition, and/or planning when
ADHD patients were compared with normal controls. However, PPP was limited when ADHD patients
were compared with controls with attention or related problems, suggesting that the tests' ability to
identify ADHD patients among patients referred for attention problems is limited. In addition, negative
predictive power (NPP), or the percentage of patients with normal scores not receiving an ADHD
diagnosis by standard criteria, was low to moderate for most tests, suggesting that neuropsychological
test scores should not be used to rule out ADHD. Thus, the utility of these tests for diagnosing ADHD
in clinical practice appears to be low. (Hayes, Neuropsychological Testing for Attention-Deficit
Hyperactivity Disorder (ADHD), 2008)

Hayes reviewed the following studies (Hayes, Neuropsychological Testing for Attention-Deficit
Hyperactivity Disorder (ADHD), 2008): Two studies evaluated the Test of Variables of Attention
(TOVA). In a small study including 28 children with ADHD and 20 normal controls, the predictive



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power of the TOVA was good, with a PPP of 80% and NPP of 78% (Schatz et al., 2001). However, a
larger study including 116 children with ADHD and 51 controls with subclinical levels of
attention/behavior problems yielded a PPP of 69 and NPP of 30, indicating poor predictive power for
the TOVA (Preston et al., 2005). The Conners' Continuous Performance Test (CCPT) was evaluated in
three studies. Perugini et al. (2000) reported that PPP and NPP for the CCPT were 70% when
comparing children with ADHD to normal controls. Similarly, when adults with ADHD were
compared with normal controls, the PPP and NPP were 86% and 71%, respectively (Walker et al.,
2000). However, in a recent study in which the control group consisted of children without ADHD but
with attention problems, CCPT scores were not associated with parent and teacher ratings of ADHD-
related behaviors and the predictive power of the test was poor. (Edwards et al., 2007)

Three separate studies evaluated the Gordon Diagnostic System (GDS). In a study to validate the
(GDS) for Swedish children, the predictive value of GDS scores was poor when children with ADHD
were compared with normal controls (El-Sayed et al., 1999). A study in which the GDS was used to
identify ADHD in children with a preschool history of language problems reported that the PPP was
low (20% to 37%), while the NPP was high, ranging from 72% to 88% (Rielly et al., 1999). In another
study of children with learning, attention, or behavioral problems, the difference between IQ score and
GDS score yielded a PPP in the high range (80% to 92%), while the NPP was lower (52% to 70%)
(Dickerson Mayes et al., 2001). The highest predictive power was observed when, in the same sample
with some additional subjects, the GDS score (relative to IQ) was combined with the freedom from
distractibility index (FFDI) score (relative to IQ): the PPP remained high (92%), while the NPP
increased substantially (86%). (Mayes and Calhoun, 2002)

Wechsler Intelligence Scale for Children Freedom-from-Distractibility/Working Memory Index
(FDI/WMI), Processing Speed Index (PSI), and Gordon Diagnostic System (GDS) scores in 587
ADHD children were examined as a function of subtype and coexisting anxiety, depression, and
oppositional-defiant disorder. Attention scores (FDI/WMI and GDS Vigilance and Distractibility) were
similar and low for all groups. ADHD combined groups had greater impulsivity (GDS Delay) than
ADHD inattentive groups, and ADHD inattentive groups had slower processing speed (PSI) than
ADHD combined groups. Comorbidity did not affect test performance. Scores differentiated ADHD
subtypes with 72% accuracy. According to the investigators, these findings support the validity of
DSM-IV ADHD combined and inattentive subtypes and the validity of the GDS, FDI/WMI, and PSI in
assessing attention, impulsivity, and processing speed in children with ADHD (Mayes, 2009).

Wahlsted (2009) investigated possible independent and combined effects of inhibitory control, delay
aversion, and reaction time (RT) variability in relation to symptoms of hyperactivity/impulsivity and
inattention in a study that included 111 school children. Behavioral symptoms were measured through
parental and teacher ratings of the DSM-IV criteria for ADHD and Oppositional defiant disorder
(ODD). The results showed that inhibitory control and RT variability were primarily related to
symptoms of inattention rather than hyperactivity/impulsivity. Further, out of the three
neuropsychological factors studied, only inhibitory control contributed uniquely to the variance of
ADHD symptoms. However, significant interaction effects of delay aversion and RT variability on
symptoms of both hyperactivity/impulsivity and inattention were found. According to the
investigators, this study shows the importance of searching for possible combined effects of
neuropsychological factors to learn more about the different pathways that lead to ADHD symptoms in
children.



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Rizzutti et al. (2008) evaluated clinical and neuropsychological findings in children with suspicion of
attention deficit hyperactivity disorder (ADHD). 75 children fulfilled the criteria for ADHD, among
which 35 were of the inattentive type, 28 of combined type and 12 were hyperactive/impulsive. There
was negative correlation between the digit score and the Corsi test. Children with hyperactivity and
impulsivity had a low performance for functional memory. Children with oppositional defiant disorder
presented pattern changes in adaptability when there was a change in the rhythm the stimuli were
presented and lower adaptation to time variability (Hit RT), in addition to higher rates of omission in
the continuous performance test. According to the investigators, this study suggests multiple
interrelations between the scores of neuropsychological battery useful for the clinical profile of
children with ADHD.

Several other studies have indicated that neuropsychological testing is beneficial to evaluate specific
neuro-cognitive behavioral deficits related to ADHD (Leitner, 2007; Martinussen, 2006).

Brain and Cranial Lesions
Krupp et al. (2009) performed a comprehensive evaluation in 91 patients after supratentorial
meningioma surgery in a retrospective study. A significant negative correlation between patient age
and cognitive performance was found, with a major decline beginning at the age of 55 years.
According to the investigators, comprehensive evaluation after meningioma surgery is required to
prevent poor long-term results after apparently successful surgery.

Kramer et al. (1997) investigated the neuropsychological consequences of medulloblastoma in 10
adults. A battery of tests was conducted to assess global intellectual functioning, verbal ability,
visuospatial ability, memory, reasoning, and academic proficiency. For the verbal memory
performance, each patient was matched with two normal controls selected on the basis of age, sex, and
level of education. Mean dose of whole brain radiation was 34.5 Gy. Mean interval between diagnosis
and testing was 79.1 months. Test results demonstrated below average intelligence quotients (mean
intelligence quotient 90.2; range 67-103) and specific deficits in memory, reasoning, visuospatial
ability, and arithmetic. The investigators concluded that adults with medulloblastoma in a prolonged
disease-free status may suffer significant cognitive deficits.

Schick et al. (2008) analyzed temporal lobe gliosis and temporal lobe dysfunction after middle fossa
vestibular schwannoma surgery in a study that included 32 patients after enlarged middle fossa surgery
(EMFS) and 20 subjects for control. Study interventions included magnetic resonance imaging of the
temporal lobe 1 year after treatment and neuropsychological testing (Berliner Amnesia Test [BAT],
Boston Naming Test [BT], Token Test). Temporal lobe gliosis after EMFS was observed in 22 of 32
analyzed patients (degree of gliosis: 11, slight; 9, moderate; 2, severe). Neuropsychological testing of
23 of the 32 previously analyzed patients after EMFS compared with control subjects (n=20) found
only in few sub-domains (figural score, personality test) statistically significant worse test results, but
no major disturbances of the temporal lobe function compared with the control group. Only one patient
with a finding of severe temporal lobe gliosis was proven in the BAT and BT to have a temporal lobe
deficit. The investigators concluded that in a significant number of patients, temporal lobe gliosis has
to be expected after EMFS; however, the gliosis is only slight or moderate in most of the patients and
not associated with essential functional deficits of the temporal lobe. Nevertheless, the possibility of a




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severe temporal lobe gliosis with functional deficits in the BAT and BT has to be taken into
consideration.

Papazoglou et al. (2008) examined the time-dependent effects of radiation treatment on adaptive
functioning in 22 children with brain tumors. Attention span was found to mediate the relationship
between time since the initiation of radiation and daily living skills. These findings were shown to be
specific to attention and not a reflection of generalized neuropsychological decline. According to the
investigators, the results of this study suggest that time since radiation may directly decrease attention
and poor attention in turn may be associated with lower adaptive functioning on tasks of daily living.

Visani et al. (2006) evaluated the long-term cognitive deficits of 20 patients who suffered a brain
abscess (BA) and estimated its effect on the quality of life. Follow up with neuropsychological and
behavioral tests was performed 6 months to 42 years after BA. Cognitive deficits were defined as a test
score of 2 or more standard deviations below controls' mean in those tasks which revealed a significant
group deficit. Compared with healthy age, sex and education-matched controls, 13 of 20 patients
(65%) exhibited neuropsychological deficits in some cognitive tasks. Ten of those patients (50%) were
significantly impaired in up to 2 cognition domains, while the remaining three patients (15%) showed
three to five impaired domains. No correlation was found between neuropsychological impairments
and patients' age, sex, initial neurological symptoms, size and localization of BA, or secondary
epileptic seizures. Reduction in quality of life was found in five patients (25%). The investigators
concluded that BA may cause long lasting cognitive deficits. Despite the focal character of the lesion,
long-term sequelae follow a more diffuse subcortical deficit pattern.

Dementia, Possible Dementia, Memory Loss, and Memory Impairment
For memory impairment or dementia screening, a single test of global measures of function or a
measure of cognitive function is usually administered along with a test of behavioral or emotional
symptoms. In addition to brief screening tests, for some patients, comprehensive neuropsychological
testing may be indicated to confirm a diagnosis, evaluate effects of treatment, and assist in designing
rehabilitative or intervention strategies for the patient. Standardized test batteries are too long for most
patients with dementia; specialized dementia batteries or an individualized test battery is usually more
appropriate. Expert opinion is that at least a brief reevaluation should be done yearly, with more
extensive testing in cases of reversible dementia.

A definitive diagnosis of Alzheimer's disease is based on the presence of memory deficits along with
deficits in at least one other aspect of cognition, and in some cases is made on neuropsychological test
results alone. (Talwalker, 1996) Impairment in primary (short-term) memory alone is not a useful
diagnostic marker for Alzheimer's disease in the early stages. Tests of delayed recall (long-term
memory) and retrieval of facts of common knowledge have been shown to be the most useful measures
to distinguish normal aging and early Alzheimer's disease. Dementia due to Alzheimer's disease can be
distinguished from dementia due to vascular disease by differences in pattern of memory impairment
and the progressive nature of Alzheimer's disease. There is sufficient data to recommend the evaluation
and clinical monitoring of persons with mild cognitive impairment due to their increased risk for
developing dementia (Petersen, 2001, Fleisher, 2007, Lohrner, 2005). Careful interpretation of test
results, taken in conjunction with medical findings, allows differentiation of Alzheimer's disease from
normal memory loss due to aging, and from vascular dementia.




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Geroldi et al. (2008) assessed the added diagnostic value of neuropsychologic tests and structural
neuroimaging (computed tomography or magnetic resonance) in the routine clinical assessment of
demented patients. The investigators concluded that the added value of structural imaging and
neuropsychologic testing in the routine clinical assessment of demented patients is substantial in both
Alzheimer disease and non-Alzheimer disease cases.

Rouch et al. (2008) assessed the relationship between cognitive complaints, objective memory and
executive performance and affective disorders in a study of 937 community-dwelling elderly
individuals. Cognitive performances were measured via a large battery of memory and executive-
performance tests chosen for their capacity to detect subtle cognitive impairment. Cognitive
complaints were associated with lower scores on verbal-memory tests and several executive-
performance tests. The investigators concluded that cognitive complaints of the elderly can reflect
objective memory and executive-performance impairments, independent of affective disorders.
Cognitive complaints should be assessed using both memory and executive-performance tests.

Saxton et al. (2004) evaluated 693 individuals who completed neuropsychological testing in 1991/1992
and were then followed over the next 8 years. The 72 individuals who were ultimately diagnosed with
Alzheimer's disease had poorer scores on baseline neuropsychological testing than those who were not
diagnosed with Alzheimer's disease.

Meulen et al. (2004) conducted a study to evaluate the seven minute screen, a neurocognitive screening
test to detect dementia. A total of 542 patients with various types of dementia and 45 healthy controls
were screened. The sensitivity of the seven minute screen for Alzheimer's was 92.9% with a specificity
of 93.5%, and the investigators concluded that this screening test is useful for discriminating patients
with dementia from patients without cognitive defects.

Gilman et al. (2005) compared the usefulness of neuropsychological testing and positron emission
tomography (PET) in differentiating Alzheimer's disease from dementia. Twenty-five patients with
Alzheimer's disease, 20 with dementia with Lewy bodies, and 19 normal elderly controls were
included in the study. The investigators found that neuropsychological testing differentiated the groups
and that family ratings of motor functioning were as robust as PET.

Pseudodementia, a dementia of "nonorganic" etiology, is due to profound depression and can be
difficult to differentiate from true dementia. The Geriatric Depression Scale is commonly used for
evaluating depression in elderly people. Prospective studies have shown increased accuracy in
differentiating pseudodementia from true dementia with repeated testing 12-18 months later. (Yousef,
1998) This is a vital distinction to make, as organic dementia is often progressive and is usually not
reversible, while dementia associated with depression may reverse or resolve with treatment.

In a prospective study, Lehrner et al. (2005) determined the annual conversion rate to Alzheimer
disease (AD) among patients reporting memory problems, including a subgroup with amnestic mild
cognitive impairment (aMCI), and investigated the predictive value of neurocognitive testing for future
dementia. One hundred and seven patients underwent a clinical examination and completed a battery
of standard cognitive tests at study entry and two years later. The conversion rate to clinically
manifested AD two years later was investigated and sensitivity, specificity, receiver operating
characteristics (AUC), positive predictive value and negative predictive value for each



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neuropsychological test were determined. A 6.5% annual rate of conversion to AD was found among
patients reporting memory decline. Specifically, patients with aMCI had an annual conversion rate of
approximately 20%. The annual conversion rate for patients reporting memory problems but showing
no memory deficit at memory testing was approximately 3%. The investigators concluded that patients
with aMCI have 8.6-fold higher odds of developing AD compared with patients without evident
memory impairment on neuropsychological testing. Although the risk of developing AD among
patients without objective memory decline is small, some patients in this group still convert to AD and
therefore close clinical monitoring of patients is necessary.

Demyelinating and Extrapyramidal Disorders
Benedict et al. (2006) evaluated the validity of the Minimal Assessment of Cognitive Function test in
291 multiple sclerosis (MS) patients and 56 healthy controls. All tests were impaired in the MS group
and most of the tests discriminated disabled from employed patients. The investigators concluded that
these tests were valid for evaluating cognitive function in MS patients.

Patti et al. (2009) evaluated the prevalence of cognitive impairment and its relation with magnetic
resonance imaging (MRI) disease measures in 327 mildly disabled patients with relapsing-remitting
multiple sclerosis (RRMS). Patients aged 18-50 years with RRMS (McDonald criteria) and an
Expanded Disability Status Scale (EDSS) score <or=4.0, who were enrolled in the Cognitive
Impairment in Multiple Sclerosis (COGIMUS) study, underwent baseline standardized MRI complete
neurological examination and neuropsychological testing. Based on the results of the study, the
investigators concluded that cognitive impairment occurs in approximately one-fifth of mildly disabled
patients with MS and is associated with specific MRI disease measures. Assessment of cognitive
function at diagnosis could facilitate the identification of patients who may benefit from therapeutic
intervention with disease-modifying therapies to prevent further lesion development.

Pokryszko-Dragan et al (2009) evaluated cognitive impairment in 21 multiple sclerosis (MS) patients
using neuropsychological testing (NT) and auditory event-related potentials (ERPs). ERPs results were
compared to age-matched controls. Correlations were searched among ERPs and NT results, duration
of MS and disability. NT and ERPs were repeated after a year and their results were compared with the
initial ones. In NT, 90 to 100% of patients showed impaired memory and attention. Latencies of ERPs
were prolonged in patients compared with controls. NT results correlated with clinical variables and
N2 parameters. Results of NT, but not ERPs, improved after a year. The investigators concluded that
NT is more useful than ERP in monitoring cognitive performance in MS patients.

Two tests, the Symbol Digit Modalities Test (SDMT) and the MS Neuropsychological Screening
Questionnaire (MSNQ), were administered to 76 patients with MS and 25 healthy controls, matched on
demographic characteristics. Tests were administered at monthly intervals, over 6 months. Results
showed that both the SDMT and MSNQ have good to excellent reproducibility over repeated testing.
In MS, there are minimal practice effects over successive tests, in the order of 0.2 SD for SDMT and
minimal change in the MSNQ. Regression analyses modeled to predict MSNQ based on SDMT and
BDIFS showed significant contribution for both, but with the majority of variance being accounted for
depression. The investigators concluded that these brief screening tests provide some independent
information about the mental status of patients with MS and are reliable, even when used in monthly,
successive examinations. (Benedict, 2008)




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Nazem et al (2008) examined the Montreal Cognitive Assessment (MoCA) performance in 100
patients with Parkinson's disease (PD) with "normal" global cognition according to Mini-Mental State
Examination (MMSE) score. As previously recommended in patients without PD, a MoCA score less
than 26 was used to indicate the presence of at least mild cognitive impairment (MCI). More than half
(52.0%) of subjects with normal MMSE scores had cognitive impairment according to their MoCA
score. Impairments were seen in numerous cognitive domains, including memory, visuospatial and
executive abilities, attention, and language. Predictors of cognitive impairment on the MoCA using
univariate analyses were male sex, older age, lower educational level, and greater disease severity;
older age was the only predictor in a multivariate model. According to the investigators, these results
suggest that MCI is common in PD and that the MoCA is a more sensitive instrument than the MMSE
for its detection.

A representative sample of 132 patients with Parkinson disease (PD) at 2 movement disorders centers
was administered the Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination
(MMSE), and a neuropsychological battery with operationalized criteria for deficits. Mild cognitive
impairment (MCI) and PD dementia (PDD) criteria were applied by an investigator blinded to the
MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and
diagnostic instruments was ascertained. Approximately one third of the sample met diagnostic criteria
for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean MoCA and MMSE scores were 25.0 and
28.1. The overall discriminant validity for detection of any cognitive disorder was similar for the
MoCA and the MMSE: The investigators concluded that the Montreal Cognitive Assessment, but not
the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument
for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive
screen using either instrument requires additional assessment due to suboptimal specificity at the
recommended screening cutoff point (Hoops, 2009).

Developmental Disorders
In general, empirical data, rather than evidence from prospective studies with long-term follow-up,
support the use of neuropsychological testing for developmental disorders in infants and children. For
the Test of Infant Motor Performance, there is evidence from a longitudinal study with subjects
stratified by postconceptional age, medical risk, and race or ethnicity that this test has predictive
validity for identifying infants at risk for poor developmental outcome. (Campbell, 1995)

Data from the Psychoeducational Profile-Revised (PEP-R) were analyzed in a sample of 46 children,
aged from 1.7 to 5.11 years, of whom 21 had autistic disorder (AD) and 25 had pervasive
developmental disorder not otherwise specified (PDD-NOS). Analysis with a t-test for independent
samples revealed a significant difference between children with AD and those with PDD-NOS on both
developmental and behavioral PEP-R scales, supporting the utility of the PEPR in discriminating
between two diagnostic groups. This study emphasizes the effectiveness of the PEP-R as a tool for the
early assessment of children with pervasive developmental disorders (Portoghese, 2009).

In a national cohort of extremely low birth weight (ELBW) children, neuropsychological test profiles
were assessed in 4 groups defined according to a neurological examination at 5 years of age: normal
neuromotor status (N = 56), motor coordination problems (N = 32), multiple subtle neuromotor signs
including both motor coordination problems and deviant reflexes (N = 20), and spastic diplegia (N =
12). The neurocognitive assessment included a test of intelligence, the Wechsler Primary and



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Preschool Scale of Intelligence-Revised (WPPSI-R) and 14 subtests of attention and executive
functions, verbal functions, manual motor functions, visuo-constructional functions and verbal
learning. The children with normal neuromotor status performed within the average range; children
with motor coordination problems had widespread impairment; and children with spastic diplegia and
children with multiple minor neuromotor signs had uneven test profiles with stronger verbal results but
weaknesses in attention and executive functions, and in manual motor and visuo-constructional tasks.
According to the investigators, very early gestation children with neuromotor signs, including motor
coordination problems, are at risk for neurocognitive impairment, in spite of average intelligence.
More impaired children have more irregular test profiles. Follow-up and neuropsychological
assessments of very preterm children with minor neuromotor signs are therefore indicated (Korkman,
2008).

Schatz et al. (2001) evaluated education attainment and neuropsychological deficits in children with
sickle cell disease (SCD) and silent cerebral infarcts. Children with silent infarcts had twice the rate of
school difficulties as children without infarcts. Eighty percent of silent infarct cases had clinically
significant cognitive deficits, whereas 35% had deficits in academic skills. Children with silent
cerebral infarcts show high rates of poor educational attainment, cognitive deficits, and frontal lobe
injury. Poor school performance in SCD is one indicator of silent infarcts.

In the Cooperative Study of Sickle Cell Disease, Wang et al. (2001) compared the results of serial
neuropsychologic testing in 373 children with sickle cell disease with the results of serial magnetic
resonance imaging (MRI) examinations, particularly to evaluate neuropsychologic function in the
absence of overt stroke. Twenty-seven patients had overt strokes and 62 had silent infarcts. Patients
with hemoglobin SS and silent infarcts had significantly lower scores for math and reading
achievement, Full-Scale IQ, Verbal IQ, and Performance IQ, when compared with those with normal
MRI findings. In children with hemoglobin SS and normal MRI findings, the scores for Verbal IQ,
math achievement, and coding (a subscale of Performance IQ) declined with increasing age. The
investigators concluded that school-aged children with sickle cell disease had compromised
neuropsychologic function in the presence of silent infarcts. In addition, they had declines in
performance in certain areas of function over time. Therapeutic interventions that prevent or lessen
cognitive impairment are needed before school entry for children with sickle cell disease.

Encephalopathy
Data from large-scale studies, laboratory studies and numerous case reports provide adequate evidence
that select neuropsychological tests are useful and indicated in the diagnosis and assessment of
neurotoxicity from a variety of causes. Although a variety of brain diseases due to opportunistic
infections or tumors can affect acquired immunodeficiency syndrome (AIDS) patients, there is a
human immunodeficiency virus (HIV)-associated encephalopathy which appears to be due to effects of
the HIV virus itself. This condition can begin with subtle symptoms of concentration or memory
problems, and can progress to full-blown dementia with accompanying motor disorders. Although
AIDS dementia does not respond to any treatment, diagnostic effort including neuropsychological
testing may be indicated in some patients to differentiate dementia from a potentially treatable
condition due to an opportunistic infection. Martin et al. evaluated neurocognitive functioning in 41
HIV-infected children treated with highly active antiretroviral therapy (HAART) (Martin, 2006). It
was determined that HIV-infected children treated with HAART remain at risk for developing central
nervous system disease and that neuropsychological testing is important to assess cognitive functioning



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in these children. A study conducted by Carey et al. (2004) evaluated screening batteries for detecting
HIV-related neuropsychological impairment in 190 HIV-infected patients. Results showed that several
tests combinations demonstrated diagnostic accuracy in detecting neuropsychological impairment and
identified who could benefit from more extensive neuropsychological evaluation. Skinner et al (2009)
analyzed the relative performance of the HIV Dementia Scale (HDS), International HIV Dementia
Scale (IHDS) and the Mini-Mental Status Exam (MMSE) together with neuropsychological tests
(Symbol-Digit, Grooved Pegboard and Trail Making) in HIV-1- seronegative subjects (HIV-; n=13)
and in HIV-1-seropositive subjects with HIV-associated neurocognitive disorder (HAND)
(HIV+HAND; n=13) and other neurological disorders (HIV+OND; n=20). Established
neuropsychological tests consistently showed significantly poorer performance by HIV+HAND
subjects compared with the other two groups.

Bajaj et al (2008) assessed the diagnostic properties of the Inhibitory Control Test (ICT) to diagnose
(minimal hepatic encephalopathy) MHE. The results of this study suggest that ICT is a sensitive,
reliable, and valid test for MHE.

Lyme disease encephalopathy results from invasion of the spirochete Borrelia burgdorferi into the
nervous system. Fifteen percent of patients with untreated Lyme disease can develop neurological
symptoms including cranial neuropathies, meningitis or painful radiculopathy. (Schneider, 2002)
Patients also can have symptoms of depression with Lyme disease. Neuropsychological testing can
help in the differentiation of depression and memory impairment of an organic nature. Patients with
Lyme encephalopathy will show mild to severe decreases of verbal fluency and verbal short-term
memory impairments, while patients with mild depression will demonstrate few of these signs on
objective testing. (Fallon, 1997) Objective findings of impairment on neuropsychological testing are
noted in 50-60% chronic Lyme disease patients. (Loigian, 1990)

Encephalopathy may also occur in association with systemic lupus erythematosus (SLE) resulting in
neuropsychiatric manifestations (Kur, 2006; Moritani, 2001).

Neurotoxin Exposure
Dementia can result from neurotoxicity due to exposure to substances such as organic solvents,
environmental pollutants, and drugs or alcohol. Neurotoxicity due to chronic alcoholism is best
diagnosed using neuropsychological testing in conjunction with a history of alcohol abuse and medical
findings. Several tests, including the Block Design subtest of the Wechsler Adult Intelligence Scale-
Revised, the Category Test (subtest of the Halstead-Reitan Neuropsychological Battery) and memory
tests have been found to be particularly useful in detecting impairment in alcoholic patients, and in
large case control studies, test results have correlated with abnormal findings on CT scans.

Seizure Disorder
Rosche et al. (2004) evaluated the role of neuropsychological testing by analyzing 40 patients with
epilepsy refractive to therapy. These patients were subjected to a 45-minute neuropsychological
screening battery and a short battery bedside test. The longer neuropsychological test was
recommended as a screening method to detect cognitive deficits in patients with chronic epilepsy.

Vinayan et al. (2005) examined the educational performance and neuropsychological functions along
with clinical and electrographic characteristics in a cohort of children with Benign Epilepsy of



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Childhood with Centrotemporal Spikes (BECTS). Neuropsychological and language tests were
administered to children who had educational problems. Fifty children who met the criteria for BECTS
were included in this study. Atypical seizure characteristics for BECTS were observed in 26 (52%)
children. Educational problems were identified in 27 children (54%); 19 of them had
neuropsychological or language impairment.

Taylor et al. (2010) compared the cognitive profile of newly diagnosed untreated epilepsy patients with
healthy volunteers using a comprehensive neuropsychological test battery. A total of 155 untreated
patients with newly diagnosed epilepsy, and no known brain pathology, were assessed before the start
of treatment with antiepileptic medication. Their scores across the neuropsychological measures were
compared with 87 healthy volunteers from the general population equated for age and sex. After
adjusting for age, sex, and education, patients with epilepsy performed significantly worse than healthy
volunteers on 6 of 14 cognitive measures, particularly in the domains of memory and psychomotor
speed. The investigators concluded that newly diagnosed untreated patients with epilepsy are
cognitively compromised before the start of antiepileptic drug medication. The domains most affected
are memory and psychomotor speed. More than one-half of the patients had at least one abnormal test
score across the test battery. There were no differences in epilepsy-related or mood variables between
those who demonstrated dysfunction and those that did not.

Neuropsychological assessment may be performed before epilepsy surgery to predict possible
postsurgical cognitive deficits (Potter, 2009; Loring, 2008; Carreno, 2008, Battaglia, 2006, Sanyal,
2005).

Stroke
In a prospective study, Henon et al. (2001) evaluated 258 patients who presented to the acute stroke
unit over a 28-week period. Follow-up evaluations were done to determine the incidence of post-stroke
dementia. After taking into account deaths prior to evaluation points at 6, 12, 24 and 36-months post
stroke, the incidence of post stroke dementia was 12.3 new cases per 100 person-years.
Neuropsychological testing in the evaluation of patients with stroke is limited in those patients who are
aphasic or have significant physical impairment. Despite these limitations, neuropsychological testing
can assist the clinicians in determining cognitive deficits associated with stroke beyond other physical
impairments which may be more obvious. Transient ischemic attacks may also be associated with
memory and cognitive impairment (Takahashi et al, 2009; Sachdev et al, 2004).

Traumatic Brain Injury
Longitudinal and case controlled studies along with numerous case reports support the use of
neuropsychological tests to assess the severity of injury and the prognosis for patients with closed head
trauma, to monitor progression, and to provide measures of outcome for determining degree of
recovery (Baum, 2008; Kalmar, 2008; Greve, 2008). Sufficient scientific evidence from a variety of
sources exists to prove the efficacy of neuropsychological testing in the immediate and long-term
evaluation of brain-injured patients.

In a cohort prediction study, Boake et al. (2001) evaluated whether neuropsychological testing is
beneficial in predicting productivity outcome after traumatic brain injury. A total of 293 adults with
traumatic brain injury underwent neuropsychological testing before rehabilitation discharge. Normal
range scores on these tests increased the probability of productive outcome by 40 to 130% and the



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investigators concluded that neuropsychological testing can predict long-term productivity. Another
study conducted by Atchison et al. (2004) assessed the relationship of neuropsychological test scores
to current productivity in 518 individuals with traumatic brain injury. Study results indicated that
neuropsychological testing provided important information regarding the ability to return to productive
activities.

Unproved Diagnoses
Intermittent Explosive Disorder
There are no clear underlying medical issues associated with intermittent explosive disorder, nor are
there published clinical trials that support the use of neuropsychological testing for this disorder.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the
American Psychiatric Association, the following criteria must be met in order for a patient to be
diagnosed with intermittent explosive disorder:
  • Multiple incidents in which the person failed to resist aggressive impulses that resulted in
      deliberate destruction of property or assault of another person.
  • The degree of aggressiveness expressed during the incidents is completely out of proportion with
      the precipitating event.
  • The aggressive episodes aren't accounted for by another mental disorder and are not due to the
      effects of a drug or a general medical condition.

Migraine Headaches
Literature addressing the neuropsychological consequences of migraine headaches is not conclusive.
Studies on the relationship between migraine and cognitive functioning have demonstrated conflicting
results. Some studies show a detrimental effect of migraine on cognitive skills (Calandre, 2002). Other
studies have shown no difference in cognitive skills for patients with migraine headaches (Gaist, 2005;
Pearson, 2006).

Mongini et al. (2005) evaluated whether neuropsychological tests demonstrate a frontal lobe
dysfunction in patients with chronic migraine. The Gambling Task (GT), the Tower of Hanoi-3 (TOH-
3) and the Object Alternation Test (OAT) were administered to 23 female patients previously treated
for chronic migraine and to 23 healthy women who were similar to the patients in age and educational
level, and the mean test scores of the two groups were compared. The patient group scored
significantly higher than the controls on the TOH-3 and, especially, the OAT.

In the patients, no significant relationship was found between the neuropsychological test scores and
those for the Minnesota Multiple Personality Inventory (MMPI), the Spielberg State-Trait Anxiety
Inventory (STAI), and the Beck Depression Inventory (BDI). The investigators concluded that the data
suggest a relationship between chronic headache and dorsolateral function (as tested by the TOH-3)
and orbitofrontal function (as tested by the OAT). The decision-making function related to
ventromedial prefrontal cortex (tested by the GT) did not show a statistically significant difference
between patients and controls. These neuropsychological findings seem to be partly independent of the
patient's psychological traits and psychiatric disorders. This study was limited by as small sample size.

Roebuck et al. (2007) compared the use of 2 techniques designed to assess statistical change, the
Reliable Change Index (RCI) and regression based methods (REG) calculated from 28 individuals with
migraine. These methods were then applied to an independent sample of 25 individuals with migraine


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who were assessed with Automated Neuropsychological Assessment Metrics (ANAM) at baseline,
headache, and following pharmacologic treatment. Traditional repeated measures analyses
demonstrated declines in cognitive efficiency following migraine onset on two of four ANAM tasks
and significant improvement on all ANAM tasks following treatment. Rates of deterioration and
improvement did not significantly differ between RCI and REG methods. A combined ANAM score
categorized the most individuals as demonstrating cognitive change, revealing that 60% of subjects
declined in performance following headache and 84% improved following migraine treatment. This
study was limited by small sample size.

There is insufficient clinical evidence to conclude that the use of neuropsychological testing for
patients with migraine headaches without associated cognitive disorders can be used effectively for
clinical decision making to improve management of this condition.

History of Myocardial Infarction
Literature addressing the neuropsychological consequences of myocardial infarction is not conclusive.
Studies on the relationship between myocardial infarction and cognitive functioning have
demonstrated conflicting results. Some studies show a detrimental effect of myocardial infarction on
cognitive skills (Sauve, 2009; Almeida, 2008). Other studies have shown no difference in cognitive
skills for patients with myocardial infarctions (Ahto, 1999, Grubb, 2000).

Moser et al. (1999) examined neuropsychological functioning among a sample of cardiac rehabilitation
(CR) patients. Using neuropsychological instruments, patients were compared in a CR program to age-
matched outpatient control subjects who had no known history of cardiac or neurologic disease.
Cardiac rehabilitation patients were then divided into dichotomous subgroups based on whether they
had undergone coronary artery bypass grafting, had experienced a myocardial infarction, had
hypertension, or had impaired ejection fraction. Neuropsychological functioning was examined relative
to each of these factors. Cardiac rehabilitation patients had poorer neuropsychological test performance
than did control subjects, with subtle relative deficits on measures of response generation, memory,
and verbal abstraction, and particularly verbal fluency. Low ejection fraction, hypertension, and prior
coronary artery bypass graft were associated with greater relative neuropsychological impairments.
Although CR patients were not grossly neuropsychologically impaired as a group, it appears highly
likely that many within a given program exhibit some degree of neuropsychological dysfunction.
According to the investigators, including neuropsychological screening as part of pre-CR testing would
help to identify such patients. Further prospective clinical trials are necessary to confirm that
neuropsychological testing is beneficial for patients who have experienced a myocardial infarction.

Neuropsychological data were gathered from 46 healthy controls, 42 cardiac patients referred for
percutaneous coronary intervention (PCI), and 43 cardiac patients referred for coronary artery bypass
grafting (CABG). Fourteen cognitive function tests were utilized at baseline and at three time points
after surgery (3 weeks, 4 months, 1 year). No clear pattern of group differences or change at follow-up
emerged. A greater percentage of CABG patients than controls worsened in seven tests (three at 1
year), but a greater percentage of PCI patients than controls also worsened in seven tests (three at 1
year). Generalized estimating equations showed only two tests (Wechsler Adult Intelligence Scale,
Third Edition, Digit Symbol, and Hopkins Verbal Learning Test, Revised, Total Recall) to be
significantly different between groups from baseline to 1 year. Compared with healthy controls, more
PCI patients than CABG patients worsened in the former of those two tests, whereas more PCI and



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CABG patients improved on the latter. The investigators concluded that current CABG procedure does
not appear to create cognitive decline (Sweet, 2008).

Wolfe et al. (2006) evaluated whether an association exists between severity of heart failure and
cognitive abilities in 38 patients. Patients were individually assessed using four standardized
neuropsychological tests that examined current and premorbid intelligence, memory and executive
functioning. Although there was no significant decline from premorbid general intellectual function,
other specific areas of deficit, including impaired memory and executive functioning, were identified.
There were no significant correlations between heart failure severity and the neurocognitive measures
used. According to the investigators, the study results support the need to recognize cognitive
impairment in individuals with heart failure and the need to develop an abbreviated method of
assessing cognitive function that can be easily implemented in the clinical setting. Identifying
cognitive deficits in this population will be useful in guiding the content and nature of treatment plans
to maximize adherence and minimize worsening of heart failure symptoms. This study is limited by
small sample size and lack of a control group.

There is insufficient clinical evidence to conclude that the use of neuropsychological testing for
patients with myocardial infarction without associated cognitive disorders can be used effectively for
clinical decision making to improve management of this condition.

Professional Societies
American Academy of Neurology (AAN): The AAN published a report regarding
neuropsychological testing of adults. This report indicates that neuropsychological testing is most
useful for management planning in patients with suspected dementia, multiple sclerosis, Parkinson's
disease, traumatic brain injury, stroke, and HIV encephalopathy. It is also useful for detecting deficits
in patients with particularly high premorbid intelligence levels in which bedside-type clinical testing
may be insensitive to mild alterations. Neuropsychological testing also has an important role in
evaluating patients undergoing epilepsy surgery. (Cummings, 1996)

The Quality Standards Subcommittee of the AAN published an evidence-based review for the early
detection of dementia. (Petersen, 2001) The recommendations state that neuropsychologic batteries are
useful to identify patients with dementia, particularly when administered to an increased-risk
population (i.e., those with cognitive impairment).

A practice parameter for the screening and diagnosis of autism developed by the American Academy
of Neurology and the Child Neurology Society indicates that neuropsychological, behavioral, and
academic assessments should be performed as needed, in addition to the cognitive assessment, to
include social skills and relationships, educational functioning, problematic behaviors, learning style,
motivation and reinforcement, sensory functioning, and self-regulation for the diagnosis of autism.
(Filipek, 2000)

American Psychological Association (APA): The American Psychological Association, Presidential
Task Force on the Assessment of Age-Consistent Memory Decline and Dementia published guidelines
for the evaluation of dementia and age-related cognitive decline. (APA, 1998) These guidelines state
that, "Comprehensive neuropsychological evaluations for dementia and age-related cognitive decline
include: tests or assessments of a range of multiple cognitive domains, typically including memory,



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attention, perceptual and motor skills, language, visuospatial abilities, problem solving, and executive
functions. It is recognized, however, that detection of profound dementia may not require a
comprehensive neuropsychological test battery."

American Psychiatric Association: The American Psychiatric Association's position statement on
HIV-related neuropsychiatric findings indicates that providers should be aware of the
neuropsychological manifestations of HIV and the importance of assessment and treatment when
patients demonstrate signs of clinically significant neuropsychological impairment. (The American
Psychiatric Association, 2003)

The American Psychiatric Association published practice guidelines for the psychiatric evaluation of
adults. The following statements were made in the guidelines regarding neuropsychological testing
(American Psychiatric Association, 2006):
  • The testing has a broad range of application, but the decision to order neuropsychological testing
      for an individual patient remains a matter of clinical judgment.
  • The testing may be requested when cognitive deficits are suspected or there is a need to grade for
      severity or progression of deficits over time.
  • The testing can be helpful in distinguishing between cognitive disorders and malingering or
      factitious disorders. When patients present later in life with the new onset of psychosis or mood
      disorder accompanied by cognitive deficits, neuropsychological testing may also be helpful in
      distinguishing dementia from other psychiatric syndromes.

In its guidelines on the treatment of AD and other dementias, the American Psychiatric Association
states: "a variety of research definitions for mild cognitive impairment are in place, but there is no
consensus on the optimal definition. The most widely accepted definition requires the following:
  1. subjective cognitive complaints,
  2. evidence of objective deficits in cognitive function based on age- and education-adjusted norms
       on standardized neuropsychological tests,
  3. intact daily functioning,
  4. evidence of cognitive decline from a prior level, and
  5. evidence of not meeting the criteria for dementia." (American Psychiatric Association, 2007)

American Academy of Pediatrics (AAP): As stated in a clinical practice guideline, the AAP does not
support the use of continuous performance tests in the diagnosis of ADHD. (AAP, 2000)

A joint statement for learning disabilities, dyslexia, and vision from the American Academy of
Pediatrics, Section on Ophthalmology, Council on Children with Disabilities; American Academy of
Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; and the
American Association of Certified Orthoptists states that children who exhibit signs of learning
disabilities should be referred for educational, psychological, neuropsychological, and/or medical
diagnostic assessments. (APA, 2009)

American Academy of Child and Adolescent Psychiatry (AACAP): Practice parameters from the
American Academy of Child and Adolescent Psychiatry state that patients with autism may need
neuropsychological and/or achievement testing depending on the clinical context. (American Academy
of Child and Adolescent Psychiatry, 1999)


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The AACAP has published practice parameters for the assessment and treatment of children and
adolescents with ADHD. The ACCAP indicates that neuropsychological testing is not required as part
of a routine assessment for ADHD, but may be indicated by the findings of the standard psychological
assessment. (Pliszka, et al., 2007)

International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN): A guideline
prepared by the Commission on Neuropsychological Assessment of Hepatic Encephalopathy appointed
by the ISHEN states that neuropsychological testing is an established methodology for quantifying
cognitive impairment due to various forms of encephalopathy, including low-grade or minimal hepatic
encephalopathy. (Randolph, 2009)

National Academy of Neuropsychology (NAN): In a policy for the evaluation of childhood learning
disorders, the NAN states that when comprehensive information about a child’s brain-related strengths
and weaknesses is necessary to understand potential sources of the problem and implications for
functioning, a neuropsychological evaluation is most often the best choice (Silver, 2006).

In a position paper on the diagnosis and management of sports-related concussion, the NAN states that
neuropsychological evaluation is recommended for the diagnosis, treatment, and management of
sports-related concussion at all levels of play (Moser, 2007).

Additional Search Terms
Psychometric testing, neurocognitive testing


APPLICABLE CODES

The codes listed in this policy are for reference purposes only. Listing of a service or device code in
this policy does not imply that the service described by this code is a covered or non-covered health
service. Coverage is determined by the benefit document. This list of codes may not be all inclusive.

     CPT® Code            Description
                          Neurobehavioral status exam (clinical assessment of thinking, reasoning and
                          judgment, e.g., acquired knowledge, attention, language, memory, planning
        96116             and problem solving, and visual spatial abilities), per hour of the
                          psychologist's or physician's time, both face-to-face time with the patient and
                          time interpreting test results and preparing the report
                          Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological
                          Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per
        96118             hour of the psychologist's or physician's time, both face-to-face time
                          administering tests to the patient and time interpreting these test results and
                          preparing the report
                          Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological
                          Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with
        96119
                          qualified health care professional interpretation and report, administered by
                          technician, per hour of technician time, face-to-face


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                             Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered
         96120               by a computer, with qualified health care professional interpretation and
                             report
CPT® is a registered trademark of the American Medical Association.


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PROTOCOL HISTORY/REVISION INFORMATION

         Date             Action/Description
      11/29/2010
                          Corporate Medical Affairs Committee
      03/19/2010

The foregoing Health Plan of Nevada/Sierra Health & Life Health Healthcare Operations protocol has
been adopted from an existing UnitedHealthcare coverage determination guideline that was researched,
developed and approved by the UnitedHealthcare Coverage Determination Committee.




Neuropsychological Testing Under the Medical Benefit                                        Page 27 of 27

				
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