TL;DR: Aetna, a CVS Health company, modified CPB 0158 — its neuropsychological and psychological testing coverage policy — effective September 26, 2025. Here's what billing teams need to do.
This update to CPB 0158 Aetna governs coverage for CPT codes 96116, 96121, 96125, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, and 96146. If your practice bills neuropsychological or psychological testing for Aetna members, this policy directly controls which claims get paid and which get denied. The criteria are detailed, the exclusions are real, and the documentation bar is high.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Neuropsychological and Psychological Testing |
| Policy Code | CPB 0158 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Neuropsychology, Psychology, Psychiatry, Neurology, Rehabilitation Medicine |
| Key Action | Audit active testing orders against all five medical necessity criteria before billing CPT 96132 or 96130 on or after September 26, 2025 |
Aetna Neuropsychological and Psychological Testing Coverage Criteria and Medical Necessity Requirements 2025
The Aetna neuropsychological and psychological testing coverage policy divides covered services into three broad clinical scenarios. Each has its own medical necessity criteria. Knowing which scenario applies to your patient determines which documentation you need before you bill.
Scenario 1: Neuropsychological Testing (NPT) for cognitive impairment from medical or psychiatric conditions. This is the clearest path to coverage. Aetna covers NPT — billed under CPT 96132 and 96133 for evaluation, or 96136 through 96139 for administration and scoring — when all five of the following criteria are met:
| # | Covered Indication |
|---|---|
| 1 | The number of testing hours doesn't exceed what's reasonably needed to answer the clinical question. |
| 2 | The testing techniques are validated for the specific diagnostic question or treatment plan. |
| 3 | The techniques don't duplicate measurements of the same cognitive, behavioral, or emotional domain. |
| 4 | The instruments are validated for the member's age and population, and represent the most current version. |
| 5 | The instruments have empirically substantiated reliability, validity, standardized administration, and clinically relevant normative data. |
All five criteria must be met. One gap in documentation creates exposure for a claim denial.
Covered indications under this scenario include cognitive assessment after traumatic brain injury, stroke, or neurosurgery. They also include epilepsy, hydrocephalus, AIDS, and other medical diagnoses. Differential diagnosis between psychogenic and neurogenic syndromes qualifies. So does monitoring cognitive decline from neurological disorders.
Scenario 2: NPT or Psychological Testing (PT) to support psychiatric or psychotherapeutic treatment. This path requires a detailed diagnostic evaluation first. After that, testing is covered under CPT 96130, 96131 (PT evaluation), or 96132, 96133 (NPT evaluation) in two situations:
| # | Covered Indication |
|---|---|
| 1 | The member's history doesn't clearly point to a psychiatric diagnosis, and the question can't be resolved by interview, observation in therapy, or a level-of-care assessment. |
| 2 | The member has tried multiple medications and/or psychotherapy, hasn't progressed, and remains symptomatic. |
The same five criteria from Scenario 1 also apply here. This is a high-documentation scenario. If the medical record doesn't show a prior treatment attempt or a diagnostic ambiguity that couldn't be resolved by clinical interview, expect a denial.
Scenario 3: NPT for ADHD differentiation. Aetna covers NPT to distinguish ADHD from learning disabilities or language/communication disorders — but only when that distinction remains unclear after history and examination. Neurologically complicated ADHD cases (post-head trauma, seizures) are covered. Uncomplicated ADHD cases rarely meet medical necessity for NPT or PT.
The neurobehavioral status exam codes — CPT 96116 and 96121 — and standardized cognitive performance testing under CPT 96125 follow the same general framework. Automated testing under CPT 96146 is covered when criteria are met, but given it's a single-instrument automated tool, justifying its use under the "no redundant measures" criterion is relatively straightforward compared to multi-test batteries.
Aetna Neuropsychological and Psychological Testing Exclusions and Non-Covered Indications
A few exclusions are worth calling out directly.
Pre-surgical clearance is not covered under this policy. NPT and PT are generally not considered medically necessary for pre-surgical clearance. If a surgeon requests a neuropsych evaluation to clear a patient for surgery, don't bill it under CPB 0158. Aetna points those cases toward CPB 0157 (Obesity Surgery) for situations where a psychological evaluation is part of the surgical protocol.
Uncomplicated ADHD cases rarely qualify. Aetna's language is blunt: NPT or PT is "rarely considered medically necessary" for uncomplicated ADHD. If you're billing cognitive testing for a straightforward ADHD diagnosis with no neurological complication in the record, that claim is at high risk.
Redundant testing is explicitly excluded. The policy bars coverage for techniques that measure the same cognitive, behavioral, or emotional domain more than once. This is the criterion that most often trips up large test batteries. If your neuropsychologist routinely administers multiple instruments covering the same construct, document the clinical rationale for each — or expect pushback.
Outdated instruments are not covered. Aetna requires the most current version of any instrument used. If your practice is still running older versions of standardized tests, that's a coverage and reimbursement risk starting September 26, 2025.
Coverage Indications at a Glance
| Indication | Status | Relevant CPT Codes | Notes |
|---|---|---|---|
| Cognitive impairment after TBI, stroke, or neurosurgery | Covered | 96132, 96133, 96136–96139 | All five criteria must be met |
| Neurocognitive function for rehabilitation planning in neurological disorders | Covered | 96132, 96133, 96136–96139 | All five criteria must be met |
| Differential diagnosis: psychogenic vs. neurogenic syndromes | Covered | 96116, 96121, 96132, 96133 | All five criteria must be met |
| Monitoring cognitive decline in neurological disorders | Covered | 96132, 96133, 96136–96139 | All five criteria must be met |
| Psychiatric differential diagnosis (ambiguous presentation) | Covered | 96130, 96131, 96132, 96133 | Requires detailed diagnostic eval first; clinical interview insufficient to resolve diagnosis |
| Testing after failed medication/therapy trials | Covered | 96130, 96131, 96132, 96133 | Prior treatment attempts must be documented |
| ADHD vs. learning disability differentiation (unclear after exam) | Covered | 96132, 96133 | Neurologically complicated ADHD only |
| Pre-surgical psychological clearance | Not Covered | N/A | See CPB 0157 for surgical protocols |
| Uncomplicated ADHD (no neurological complication) | Rarely Covered | 96130, 96131, 96132, 96133 | Rarely meets medical necessity criteria |
| Redundant domain testing | Not Covered | All | Policy explicitly excludes duplicate domain measures |
| Testing with outdated instrument versions | Not Covered | All | Must use most current version of each instrument |
Aetna Neuropsychological and Psychological Testing Billing Guidelines and Action Items 2025
The real issue with CPB 0158 isn't the coverage criteria themselves — it's documentation. Every denial pattern on these claims traces back to missing or insufficient documentation at the point of service. Here's what to do before September 26, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your testing battery templates against the five criteria. Pull the standard batteries your neuropsychologists use most often. Map each instrument to the five medical necessity criteria. Flag any instruments that duplicate another in the battery. If you can't justify each instrument independently, remove it or document the clinical rationale explicitly. |
| 2 | Verify instrument versions before billing CPT 96132 or 96130. Aetna requires the most current version of every instrument. Run a current inventory. If your practice is using older normed versions of common tools, update before the effective date of September 26, 2025. |
| 3 | Build a documentation checklist for Scenario 2 cases. For psychiatric differential cases, the medical record must show a completed diagnostic evaluation, a documented reason why clinical interview couldn't resolve the question, and — if testing follows failed treatment — a documented history of prior medication and/or therapy attempts. If those elements aren't in the record before testing, you're billing at risk. |
| 4 | Flag pre-surgical testing referrals at the front end. Train your intake and scheduling staff to route pre-surgical psychological clearance requests to CPB 0157, not CPB 0158. Billing those under CPT 96130 or 96132 without appropriate documentation will result in a claim denial. |
| 5 | Review your ADHD testing protocols. If your practice bills neuropsychological testing billing for ADHD cases, categorize your active caseload. Neurologically complicated cases (documented head trauma, seizures) have a path to coverage under CPT 96132. Uncomplicated cases don't. If you're billing both under the same protocol, split them now. |
| 6 | Check your prior authorization workflows. While CPB 0158 doesn't specify a blanket prior authorization requirement across all testing scenarios, Aetna plans frequently layer prior auth requirements on top of clinical coverage policies. Confirm your prior auth process for neuropsychological and psychological testing with each specific Aetna plan before scheduling. One call before service beats one appeal after denial. |
| 7 | If your practice has high neuropsychological testing volume — especially for ADHD or psychiatric differential cases — loop in your compliance officer. The five-criteria framework creates documentation requirements that aren't always reflected in current intake and clinical workflows. A compliance review now costs less than retroactive audits later. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Neuropsychological and Psychological Testing Under CPB 0158
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 96116 | CPT | Neurobehavioral status exam — clinical assessment of thinking, reasoning, and judgment (e.g., acquired knowledge, attention, language, memory, planning, problem solving, and visual spatial abilities) |
| 96121 | CPT | Neurobehavioral status examination — each additional hour |
| 96125 | CPT | Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of technician time |
| 96130 | CPT | Psychological testing evaluation services by physician or other qualified health care professional — first hour |
| 96131 | CPT | Psychological testing evaluation services by physician or other qualified health care professional — each additional hour |
| 96132 | CPT | Neuropsychological testing evaluation services by physician or other qualified health care professional — first hour |
| 96133 | CPT | Neuropsychological testing evaluation services by physician or other qualified health care professional — each additional hour |
| 96136 | CPT | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional — first 30 minutes |
| 96137 | CPT | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional — each additional 30 minutes |
| 96138 | CPT | Psychological or neuropsychological test administration and scoring by technician — two or more tests, first 30 minutes |
| 96139 | CPT | Psychological or neuropsychological test administration and scoring by technician — two or more tests, each additional 30 minutes |
| 96146 | CPT | Psychological or neuropsychological test administration with single automated, standardized instrument |
Key ICD-10-CM Diagnosis Codes
The policy lists 257 ICD-10-CM codes. Below is the full set included in the policy data. These represent the diagnosis codes Aetna associates with covered indications under CPB 0158.
| Code | Description |
|---|---|
| E75.0 | GM2 gangliosidosis |
| E75.1 | Other and unspecified gangliosidosis |
| E75.10 | Other and unspecified gangliosidosis, unspecified |
| E75.11 | Other and unspecified gangliosidosis — GM1 |
| E75.12 | Other and unspecified gangliosidosis — GM3 |
| E75.13 | Other and unspecified gangliosidosis — Niemann-Pick disease type A |
| E75.14 | Other and unspecified gangliosidosis — Niemann-Pick disease type B |
| E75.15 | Other and unspecified gangliosidosis — Niemann-Pick disease type C |
| E75.16 | Other and unspecified gangliosidosis — Niemann-Pick disease type D |
| E75.17 | Other and unspecified gangliosidosis — Fabry disease |
| E75.18 | Other and unspecified gangliosidosis — other |
| E75.19 | Other and unspecified gangliosidosis, unspecified |
| E75.2 | Other sphingolipidosis |
| E75.23 | Krabbe disease |
| E75.25 | Metachromatic leukodystrophy |
| E75.29 | Other sphingolipidosis |
| E75.3–E75.9 | Other lipid storage disorders and related conditions |
| F01.50–F01.C4 | Vascular dementia |
| F03.90–F03.C4 | Unspecified dementia |
| F07.0 | Personality change due to known physiological condition |
| F07.89 | Other personality and behavioral disorders due to known physiological condition |
| F10.10–F19.99 | Mental and behavioral disorders due to psychoactive substance use (active abuse, withdrawal symptoms) |
| F80.0–F80.49 | Pervasive and specific developmental disorders (speech, language, and communication) |
The full 257-code ICD-10-CM list — including all F-series psychiatric codes, neurological conditions, and metabolic disorders — is available in the complete policy at CPB 0158 on PayerPolicy. Cross-reference your active diagnosis codes against the full list before billing.
Get the Full Picture for CPT 96132
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.