If you suffer from brain fog, difficulty concentrating, or memory problems, and your symptoms interfere with your ability to work, you may benefit from a neuropsychological evaluation. A neuropsychological evaluation tests for the presence and severity of cognitive deficits, in contrast with a psychological evaluation, which detects mood disorders and other mental and nervous conditions. This article will provide an overview of neuropsychological testing generally and then discuss how to use neuropsychological testing to help, or at least not hurt, your disability claim.
A neuropsychological evaluation can be a useful tool in substantiating a disability claim. The purpose of a neuropsychological evaluation is not to diagnose medical conditions (though the results can help to confirm a diagnosis), but rather to determine the extent of functional cognitive impairment caused by the patient’s medical condition. In that sense, a neuropsychological evaluation is like a functional capacity evaluation for the brain.
However, neuropsychological evaluations are not without their downsides. A neuropsychological evaluation can backfire if the examiner determines that the test results are “invalid,” “mild,” or “inconclusive.” Disability insurers are aware of those potential pitfalls and will exploit them to deny claims.
What Is a Neuropsychological Evaluation?
A neuropsychological evaluation is a series of tests administered by a neuropsychologist or clinical psychologist designed to detect abnormalities in intellect, reasoning, memory, attention, executive function, processing speed, and other cognitive functions. The testing is administered on paper or on a computer, usually in an office setting, though sometimes virtually. The neuropsychologist may have a graduate student administer the testing. The test usually lasts around 5 hours.
The raw data from the examination is converted into a scaled score and then compared against a normative sample. The test results are then characterized as “superior,” “above average,” “average,” “low average,” “borderline impaired,” or “impaired.”
The neuropsychological evaluation should include a clinical interview to discuss your medical history and current complaints. Afterward, the neuropsychologist will generate a report of his or her findings. He or she should then schedule a meeting or phone call with you to discuss the results.
A neuropsychological evaluation is usually conducted in one or two sessions, but can be broken into several sessions if, for example, the examinee suffers from fatigue. A neuropsychological evaluation is typically a limited engagement, meaning the neuropsychologist does not remain involved in the patient’s care. Evaluation more than every two years is discouraged due to concern for a rehearsal factor.
What Are Examples of Neuropsychological Testing?
Examples of tests you may encounter during a neuropsychological evaluation include:
- Wechsler Adult Intelligence Scale: An IQ test. Assesses intelligence, cognitive ability, memory, and processing speed through visual puzzles, block design, matrices, and other methods.
- Weschler Memory Scale: Tests memory. This test is administered and then re-administered after a 20-30 minute delay.
- Wisconsin Card Sorting Test: Tests executive function. The patient sorts cards according to different criteria.
- Trail Making Test: Tests visual attention and task switching by having the examinee draw a line connecting 25 dots as quickly as possible while maintaining accuracy.
The examiner will also administer psychological tests to determine if a mood disorder or other mental illness is contributing to the patient’s cognitive difficulties. Examples of such tests include the Beck Depression Inventory and the Beck Anxiety Index.
Finally, the examination should include validity testing to determine whether the examinee is giving his or her full effort. Most neuropsychological tests contain embedded validity measures that will detect if the examinee is giving less than full effort. The examiner may also administer free-standing validity tests such at the Test of Memory Malingering or the Victoria Symptom Validity Test. Finally, the examiner may draw conclusions about effort based on patient observation and consistency of the test results.
What Conclusions Can Be Drawn from a Neuropsychological Evaluation?
An examiner may conclude, from the results of a neuropsychological evaluation, whether the patient suffers from a mild, moderate, or severe cognitive disorder. The doctor may also diagnose dementia, attention deficit disorder, and mood disorders or other mental nervous conditions.
The examiner may identify isolated deficits in the areas of memory, processing speed, word retrieval, and other specific cognitive processes. Those deficits can then be translated into workplace restrictions and limitations. Examples of workplace restrictions and limitations resulting from cognitive impairment include:
- Difficulty maintaining attention, concentration, or pace
- Difficulty interacting with the public
- Difficulty learning new procedures
- Difficulty making decisions under time constraints
- Difficulty retaining information
- Difficulty adapting to changed circumstances
- Difficulty multi-tasking
If the examinee gives less than full effort, the results of the evaluation will be deemed to be unusable, and no conclusions may be drawn. Importantly, an invalid examination does not mean the patient is a malingerer. Many factors can produce an invalid examination besides malingering, including interference from pain, medication side effects, and depression.
What Types of Disability Benefits Claims Can Benefit from a Neuropsychological Evaluation?
Patients who tend to benefit the most from neuropsychological evaluation are those with organic brain disease or trauma related disability benefits claims. Examples of such impairments include:
- Stroke or brain aneurysm
- Traumatic brain injury
- Multiple Sclerosis or Parkinson’s Disease
- Encephalitis, hydrocephalus, and other conditions that cause swelling and/or inflammation of the brain
- Brain tumor
- Seizure disorder
Neuropsychological evaluations can be useful to evaluate other impairments that affect cognition, such as migraine headaches, medication side effects, chemotherapy- or fibromyalgia-induced brain fog, and Long Covid. However, the forgoing conditions can produce fatigue and other symptoms that interfere with test performance, thereby potentially producing invalid or inconclusive results. For that reason, it is best to proceed with caution and select a board-certified examiner with experience evaluating the condition in question.
How Do I Prepare for a Neuropsychological Evaluation?
A neuropsychological evaluation can last up to five hours or more. Thus, it’s important to get a good night of sleep, eat a nutritious breakfast, and bring a lunch and/or snacks.
Fight the temptation to exaggerate your impairment or give up early. You will be penalized for low effort. The Test of Memory Malingering, in particular, is designed so that even patients with dementia can produce a valid score. Giving less than optimal effort will result in an invalid exam. An invalid exam is, at best, a waste of time and money. At worst, an invalid exam is an excuse for the disability insurer to portray you as a malingerer.
How Do I Pick a Neuropsychologist?
A good place to start your search for a neuropsychologist is to look for someone who is board-certified. The American Board of Professional Psychology maintains a directory of board-certified neuropsychologists. You should then cross-reference your health insurance provider network to determine which neuropsychologists are both board-certified and in-network.
A psychologist need not be board-certified to administer a neuropsychological evaluation. Many psychologists who lack board certification can nonetheless conduct thorough examinations and write excellent reports. Likewise, board-certified neuropsychologists sometimes make mistakes and omissions. However, in general, board certification signifies that the examiner has undergone rigorous training and adheres to high standards. Board certified neuropsychologists also make for more authoritative expert witnesses than those lacking the designation, should your disability case go to trial.
Will Insurance Pay for a Neuropsychological Evaluation?
Most private health insurance companies and Medicare will pay for neuropsychological testing if deemed medically necessary by a treating physician. Occasionally, an insurance company may deny coverage if the exam is deemed to not serve treatment purposes. Thus, it is a good idea to check with your insurance company and obtain pre-authorization if necessary.
Some psychologists may refuse to bill insurance if they deem the examination to be “forensic,” rather than treatment-related, in nature. Thus, it can be helpful to obtain a referral for neuropsychological testing from your primary care physician, even if your health insurance policy does not require one.
Just because your insurance company will pay for a neuropsychological evaluation does not mean you should use insurance to pay for the evaluation. There are advantages to self-paying for the examination. One advantage is that the report, if unfavorable, is less likely to be discovered by the disability insurance company. However, neuropsychological evaluations are expensive and vary in cost from $1,500 to $5,000. Thus, self-paying for one is not always feasible for a disability claimant with a reduced (or no) income.
What If I Am Ordered to Attend a Neuropsychological Examination by My Disability Insurer?
Your disability can require you to attend an independent medical examination (“IME”) at its expense, by a doctor of its choosing, including a neuropsychological evaluation. If you receive such a notice, and you have not alleged disability due to organic brain disease or trauma (see above), you should object to the examination, ideally through counsel, as irrelevant and not likely to produce valid results. Don’t outright refuse to attend the examination, though, as doing so could result in your disability claim being denied due to failure to comply with the policy terms.
The primary concern, when one is ordered to attend a neuropsychological evaluation, is that the insurer will use the examination as a proxy for credibility. If you produce invalid results on the examination, the insurer may cite that as evidence that you are not trustworthy – therefore, why should your complaints of pain or cognitive difficulty be believed? The best defense against such arguments is to give your full effort on the examination. However, even if the results are deemed to be invalid, you can overcome that fact by noting that there are many reasons, besides malingering, that an examination may be invalid. Furthermore, an invalid examination is not probative of the absence of cognitive impairment; it simply means the results of the examination are unreliable.
What If I Attend a Neuropsychological Evaluation and My Results are “Mild”?
Oftentimes, individuals with a high premorbid IQ and/or high degree of professional success will subjectively perceive a diminution in their cognitive abilities, even if those abilities remain high as compared to the general population. Such individuals may be diagnosed with a “mild cognitive disorder.” The disability insurer then emphasizes that the impairments are “mild” and not likely to interfere with your ability to perform your past work or another occupation. The disability insurer may also assert that the claimant can “compensate” for any deficits by relying on his or her other intact cognitive faculties.
In such circumstances, it is crucial to emphasize the cognitive demands of the claimant’s pre-disability occupation – or, if the question is whether the claimant can adapt to another occupation, then the cognitive demands of those other occupations. The U.S. Department of Labor’s Dictionary of Occupational Titles lists the “aptitudes” required to perform an occupation (e.g., general learning ability, verbal ability, numerical ability, etc.) and describes the degree of level of aptitude required (ranging from the top 10 percent of the population to the bottom 10 percent).
Thus, if an occupation requires that a claimant have “general learning ability” in the top 10 percent of the population, but his or her neuropsychological testing reveals an IQ in the “average” range (and well below the estimated premorbid IQ), then a strong argument exists that the claimant is precluded from performing the occupation in question. Evidence that the claimant struggled at work and was unable to perform the job, even with accommodations, can provide strong corroborating support for disability.
How Can My Disability Attorney Help?
A disability insurance attorney can help counsel you as to whether neuropsychological evaluation is indicated for your diagnosis. He or she can help you to select a neuropsychologist who is board certified or else has a track record of writing quality reports. He or she can then counsel you as to what to expect the day of the examination and how to approach the testing to ensure a valid result.
After the examination, a disability attorney can help you to understand the results and counsel you as to whether they help, or hurt, your disability claim. The attorney may also identify ambiguities or holes in the report that require further elaboration. Finally, a disability attorney can compare the results of the evaluation against the requirements of your occupation (or other occupations), and highlight any discrepancies between your abilities and the abilities required of the occupation(s).
At DeBofsky Law, our firm has helped hundreds of claimants with cognitive impairment navigate this complex process. If you suffer from a disability due to cognitive impairment, and you are contemplating filing for disability, or your disability claim has been denied, call us today to discuss your options.