[Date]
Appeals Department
[Health plan name]
[Appeals address or fax]
Re: Appeal of denial of neuropsychological testing for [Patient name], DOB [Date of birth], Member ID [Member ID], Reference [Denial or case reference number]
To the appeals reviewer:
I am the treating child and adolescent psychiatrist for [Patient name], a 10-year-old whom I have evaluated and treated. I am writing to appeal the plan's determination dated [Date of denial] denying authorization of neuropsychological testing, and to request that the plan authorize the evaluation as requested by [name and credentials of the evaluating psychologist].
The referral question
The referral question is whether the patient's inattention and academic failure are explained by attention-deficit/hyperactivity disorder, by a specific learning or language disorder, by anxiety, or by a combination. Each of those leads to a different treatment, and rating scales and clinical interview cannot separate them reliably at this age.
[Add two or three sentences of specific clinical detail: the presenting problems, their duration, and the findings on your evaluation that leave the question open.]
Evaluation to date
The evaluation to date has included standardized rating scales from the parent, the teacher, and the patient, a full psychiatric diagnostic evaluation, and a request to the school for evaluation, which the school declined or cannot complete within a clinically reasonable time. These have narrowed the question but have not answered it, and no further clinical evaluation short of formal testing will. [Add dates and, for rating scales, the instruments and scores.]
What the results will change
The results of neuropsychological testing will determine the diagnosis, and with it which treatment is indicated, whether a medication is started, stopped, or changed, and which psychotherapy is indicated and how it is delivered. Without the evaluation, treatment proceeds on an unconfirmed diagnosis, which for this patient means either continuing a treatment that is not working or starting one whose indication is uncertain. Testing is medically necessary because it is the step that makes the treatment decision possible.
Response to the stated reason for denial
The denial characterizes the testing as educational. It is not. The referral question is a diagnostic question about a medical condition, the answer will change the medical and psychiatric treatment as set out above, and the testing is ordered by a treating clinician for that purpose. That the results may also be useful to a school does not make the testing educational, any more than an audiogram becomes educational because a school reads it.
Applicable requirements
The plan is subject to the Mental Health Parity and Addiction Equity Act. Diagnostic testing for a mental health or neurodevelopmental condition may not be subjected to medical-necessity standards, prior-authorization requirements, or exclusions applied more stringently than those the plan applies to diagnostic testing for medical and surgical conditions. A plan that covers neuropsychological testing after a stroke but denies it for the same referral question in a child with a psychiatric diagnosis should be examined under that standard.
Under the internal claims and appeals and external review requirements that apply to this plan, the member is entitled to a full and fair review of this denial and to the specific reason and criteria relied on. If the denial is upheld, the member will request independent external review, and this letter should be included in the record for that review.
Request
- Reverse the determination and authorize neuropsychological testing as requested, including [hours requested] hours of testing, scoring, interpretation, and report.
- Before any decision to uphold the denial, schedule a peer-to-peer review with me and ensure the reviewer is a child and adolescent psychiatrist or a psychologist with pediatric neuropsychological training.
- Provide the specific clinical criteria applied, the reviewer's written rationale, and the reviewer's name, license, and specialty.
- Include this letter and its attachments in the complete claim file for any subsequent internal or external review.
I am available to discuss this patient at any time.
Sincerely,
[Your name]
[Credentials and board certification]
[Practice or hospital]
[Direct phone and fax]
NPI [NPI]
Enclosures: [Evaluation note, rating-scale results, the evaluating psychologist's testing plan with hours by domain, relevant medical records.]