Is neuropsychological testing indicated for a 13-year-old patient with persistent concussion symptoms, including headaches, tinnitus, photophobia, and phonophobia, after a helmet-to-helmet hit during football practice?

Neuropsychological Testing is Indicated for This Patient

Neuropsychological testing is appropriate and should be approved for this 13-year-old with persistent post-concussion symptoms lasting over 5 weeks, particularly given the documented cognitive symptoms, prolonged symptom duration, and need for objective assessment to guide return-to-play and academic accommodations. 1

Clinical Justification Based on MCG Criteria

This case meets all required MCG criteria for neuropsychological testing authorization:

Patient Demonstrates Cognitive/Behavioral Impairment Requiring Quantification

• Persistent symptoms for 5+ weeks (initial injury October 2, evaluation November 7) with worsening after premature return to play 1
• SCAT6 score of 55/132 symptom severity with 16/22 symptoms positive, documenting significant ongoing impairment 1
• Documented cognitive symptoms: headaches worsening with mental activities, photophobia, phonophobia, tinnitus, and school absence requiring quantification 1
• Pain with extraocular movements suggesting ongoing neurological involvement 1

Traumatic Brain Injury as Qualifying Diagnosis

• Concussion with possible loss of consciousness from helmet-to-helmet contact meets the traumatic brain injury criterion explicitly listed in MCG guidelines 1
• The American Academy of Pediatrics identifies neuropsychological testing as "one of the cornerstones of concussion evaluation" and states it "can be helpful to provide objective data to athletes and their families after a concussion" 1

Testing Will Directly Impact Patient Care

Neuropsychological testing results will guide multiple critical management decisions:

• Return-to-play protocol timing and safety: Testing provides objective cognitive recovery data beyond symptom reporting alone 1
• Academic accommodations: The patient has missed school and needs cognitive workload modifications; testing quantifies specific deficits (attention, memory, processing speed) to guide school planning 1
• Differentiation of post-concussion syndrome: With symptoms exceeding 4 weeks, testing helps distinguish persistent concussion effects from other causes and establishes severity 1, 2
• Monitoring cognitive recovery trajectory: Cognitive recovery may precede or follow symptom resolution, making objective testing essential 1

Critical Clinical Context Supporting Authorization

Prolonged Recovery Pattern

• Symptoms persisted 2+ weeks initially, then worsened dramatically after premature return to football 2 weeks ago 1
• Current daily headaches rated 8/10 represent significant functional impairment 1
• The American Academy of Pediatrics notes that while most concussions resolve in 7-10 days, "some athletes may take weeks to months to recover" and identifies persistent symptoms beyond 1-6 weeks as meeting post-concussion syndrome criteria 1, 2

High-Risk Features Present

• Adolescent age (13 years): Pediatric athletes have longer recovery courses than adults and require more conservative management 1
• Premature return to play: Returned to football before full symptom resolution, causing symptom exacerbation—a known risk factor for prolonged recovery 1
• Possible loss of consciousness: Associated with worse outcomes and prolonged symptoms 2

Specialist Referral Already Initiated

• Brain Care Clinic referral placed by primary care physician, indicating recognition of complicated concussion requiring specialized management 1, 3
• The American Academy of Pediatrics recommends specialist referral for symptoms lasting 1-6 weeks or longer, which this patient meets 3
• PT/OT referrals also placed for pain with eye movements, demonstrating multidisciplinary approach where neuropsychological testing provides complementary cognitive assessment 1

Testing Appropriateness and Feasibility

Patient Can Participate Effectively

• Alert, interactive, no acute distress on examination 1
• Intact neurological exam including cranial nerves II-XII, suggesting ability to complete testing 1
• No active substance use documented 1

Qualified Provider and Appropriate Setting

• UW Waisman Center Brain Care Clinic is a specialized concussion center with qualified neuropsychologists 1
• Testing will be administered by appropriately credentialed providers in a specialized brain injury clinic 1

Timing is Appropriate

• Testing while symptomatic provides baseline severity data and can be repeated after symptom resolution to document cognitive recovery 1
• The American Academy of Pediatrics notes there are "no evidence-based guidelines about when to administer computerized neuropsychological tests after concussion," but testing both during symptomatic and asymptomatic phases is common practice 1
• Testing should not delay necessary cognitive and physical rest, which has already been recommended 1

Common Pitfalls to Avoid

Critical caveat: Neuropsychological testing alone does not determine return-to-play clearance. The American Academy of Pediatrics explicitly states that testing "does not independently determine if an athlete has experienced a concussion or when he or she may safely return to play" 1. A symptomatic athlete should never return to play even with normal testing 1.

Testing limitations: Without baseline pre-injury testing, results will be compared to age-based norms rather than the patient's individual baseline, which may be less sensitive for detecting subtle deficits 1. However, this does not negate the clinical utility of testing in this case with clear ongoing symptoms.

Symptom attribution: The American Academy of Pediatrics cautions about attributing all symptoms solely to concussion when symptoms may have been present at baseline 2. However, the clear temporal relationship to injury and worsening with premature return to play strongly supports concussion as the primary cause.

Authorization Recommendation

This request should be approved. The patient meets all MCG criteria with documented traumatic brain injury, persistent cognitive symptoms requiring quantification, and clear care planning needs. Testing will provide objective data to guide return-to-play decisions, academic accommodations, and ongoing treatment planning in a patient with complicated concussion recovery. 1