Attention Deficit/Hyperactivity Disorder – Medical Clinical Policy Bulletins | Aetna

Information in the [brackets] below has been added for clarification purposes.  &nbspCodes requiring a 7th character are represented by “+”:

CPT codes covered if selection criteria are met:

90791 Psychiatric diagnostic evaluation 90792 Psychiatric diagnostic evaluation with medical services 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour +96121      each additional hour (List separately in addition to code for primary procedure) 96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour +96133      each additional hour (List separately in addition to code for primary procedure) 96136 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes +96137      each additional 30 minutes (List separately in addition to code for primary procedure) 96138 Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes +96139      each additional 30 minutes (List separately in addition to code for primary procedure) 96146 Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only 96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making) 96158 Health behavior intervention, individual, face-to-face; initial 30 minutes +96159     each additional 15 minutes (List separately in addition to code for primary service) 96164 Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes +96165     each additional 15 minutes (List separately in addition to code for primary service) 96167 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes +96168     each additional 15 minutes (List separately in addition to code for primary service) 96170 Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes +96171     each additional 15 minutes (List separately in addition to code for primary service)

CPT codes not covered for indications listed in the CPB:

EEG theta/beta power ratio, Gut microbiota profile, polygenic risk score – no specific code:

0033U HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citalopram metabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G]) 0333T Visual evoked potential, screening of visual acuity, automated 70450 Computed tomography, head or brain; without contrast material 70460     with contrast material(s) 70470     without contrast material, followed by contrast material(s) and further sections 70496 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing 70544 Magnetic resonance angiography, head; without contrast material(s) 70545     with contrast material(s) 70546     without contrast material(s), followed by contrast material(s) and further sequences 70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70552     with contrast material(s) 70553     without contrast material, followed by contrast material(s) and further sequences 70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555     requiring physician or psychologist administration of entire neurofunctional testing 76390 Magnetic resonance spectroscopy 78600 Brain imaging, less than 4 static views 78601     with vascular flow 78605 Brain imaging, minimum 4 static views 78606     with vascular flow 78607 Brain imaging, tomographic (SPECT) 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation 78609     perfusion evaluation 80061 Lipid panel [serum lipid patterns] 81171 – 81172 AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis 81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) 81404 Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of dynamic mutation disorder/triplet repeat by Southern blot analysis) 82728 Ferritin 82784 Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet] 82787 Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet] 83540 Iron 83550 TIBC 83735 Magnesium 84630 Zinc 86001 Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet] 88318 Determinative histochemistry to identify chemical components (e.g., copper, zinc) 90832 Psychotherapy, 30 minutes with patient and/or family member 90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service 90834 Psychotherapy, 45 minutes with patient and/or family 90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service 90837 Psychotherapy, 60 minutes with patient and/or family member 90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service 90867 Therapeutic repetitive transcranial magnetic stimulation treatment; planning 90868      delivery and management, per session 90869      subsequent motor threshold re-determination with delivery and management 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes 90876     45 minutes 92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual 92508     group, two or more individuals 92521 Evaluation of speech fluency (eg, stuttering, cluttering) 92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) 92523     with evaluation of language comprehension and expression (eg, receptive and expressive language) 92524 Behavioral and qualitative analysis of voice and resonance 92537 – 92538 Caloric vestibular test with recording, bilateral; bithermal or monothermal 92540 Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542 Positional nystagmus test, minimum of 4 positions, with recording 92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording 92545 Oscillating tracking test, with recording 92546 Sinusoidal vertical axis rotational testing + 92547 Use of vertical electrodes (List separately in addition to code for primary procedure) 92548 Computerized dynamic posturography 92550 Tympanometry and reflex threshold measurements 92558 Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis 92567 Tympanometry (impedance testing) 92568 – 92569 Acoustic reflex testing 92570 Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 92588     comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies 92650 Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis 92651 Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report 92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report 92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report 95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) 95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition] 95813     greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition] 95816 Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition] 95819     including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition] 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 95926     in lower limbs 95927     in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929     lower limbs 95930 Visual evoked potential (VEP) testing central nervous system, checkerboard or flash 95954 Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test) 95957 Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)] 96020 Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour 96130 – 96131 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed 96902 Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality 97010 Application of a modality to 1 or more areas; hot or cold packs 97012     traction, mechanical 97014     electrical stimulation (unattended) 97016     vasopneumatic devices 97018     paraffin bath 97022     whirlpool 97024     diathermy (eg, microwave) 97026     infrared 97028     ultraviolet 97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes 97033     iontophoresis, each 15 minutes 97034     contrast baths, each 15 minutes 97035     ultrasound, each 15 minutes 97036     Hubbard tank, each 15 minutes 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 97112     neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 97113     aquatic therapy with therapeutic exercise 97116     gait training (includes stair climbing) 97124     massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) 97129 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes +97130     each additional 15 minutes (List separately in addition to code for primary procedure) 97140 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes 97151 – 97158 Adaptive Behavior Assessments and treatment 97161 – 97164 Physical therapy evaluation or reevaluation 97165 – 97168 Occupational therapy evaluation or reevaluation 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes 97810 – 97814 Acupuncture 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions 98941     spinal, 3-4 regions 98942     spinal, 5 regions 98943     extraspinal, 1 or more regions

Other CPT codes related to the CPB:

83655 Lead level 96127 Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument 96365 – 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)

HCPCS codes not covered for indications listed in the CPB:

EndeavorRx – no specific code A9583 Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist] A9585 Injection, gadobutrol, 0.1 ml G0068 Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual’s home, each 15 minutes G0129 Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes G0153 Services performed by a qualified speech and language pathologist in the home health or hospice setting, each 15 minutes G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes G0160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes G0176 Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more) G0295 Electromagnetic therapy, to one or more areas H1010 Non-medical family planning education, per session H1011 Family assessment by licensed behavioral health professional for state defined purposes J0470 Injection, dimercaprol, per 100 mg J0600 Injection, edetate calcium disodium, up to 1,000 mg J0895 Injection, deferoxamine mesylate, 500 mg J3475 Injection, magnesium sulfate, per 500 mg J3520 Edetate disodium, per 150 mg K1016 Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve K1017 Monthly supplies for use of device coded at k1016 M0300 IV chelation therapy (chemical endarterectomy) P2031 Hair analysis (excluding arsenic) S8035 Magnetic source imaging S8040 Topographic brain mapping S9128 Speech therapy, in the home, per diem S9129 Occupational therapy, in the home, per diem S9131 Physical therapy; in the home, per diem S9152 Speech therapy, re-evaluation S9355 Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9445 Patient education, not otherwise classified, non-physician provider, individual, per session S9446 Patient education, not otherwise classified, non-physician provider, group, per session T1018 School-based individualized education program (IEP) services, bundled

ICD-10 codes covered if selection criteria are met:

F90.0 – F90.9 Attention-deficit hyperactivity disorder

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