Aetna modified CPB 0214 for cognitive rehabilitation, effective February 27, 2026. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its Aetna cognitive rehabilitation coverage policy under CPB 0214 in the Aetna system. This policy governs coverage of CPT 97129, CPT +97130, and CPT 97537 for cognitive rehab services. It also explicitly blocks reimbursement for CPT 0770T (virtual reality therapy) and CPT 0615T (EyeBox), among others. If your practice bills these services to Aetna members, this policy update sets the rules for what gets paid and what gets denied in 2026.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Cognitive Rehabilitation |
| Policy Code | CPB 0214 |
| Change Type | Modified |
| Effective Date | 2026-02-27 |
| Impact Level | High |
| Specialties Affected | Occupational therapy, physical therapy, speech-language pathology, neuropsychology, psychiatry, neurology |
| Key Action | Audit all active cognitive rehab claims against the five medical necessity criteria before billing CPT 97129 or 97130 to Aetna |
Aetna Cognitive Rehabilitation Coverage Criteria and Medical Necessity Requirements 2026
Aetna's cognitive rehabilitation coverage policy sets five hard requirements for medical necessity. All five must be met — not four, not three. Miss one and you're looking at a claim denial.
Here's what the policy requires:
| # | Covered Indication |
|---|---|
| 1 | Neuropsychological testing has been performed, and those results are used in treatment planning. |
| 2 | The cognitive deficits come from a neurologic impairment — specifically moderate to severe traumatic brain injury (TBI), brain surgery, stroke, or encephalopathy. |
| 3 | A psychiatrist or psychologist has seen and evaluated the member. |
| 4 | The member can actively participate in the program. Comatose or vegetative state patients don't qualify. |
| 5 | The member is expected to make significant cognitive improvement. |
The real issue here is criterion two. Aetna draws a hard line around the qualifying causes. Moderate to severe TBI, stroke, brain surgery, and encephalopathy are in. Everything else — ADHD, depression, dementia, mild TBI, multiple sclerosis cognitive decline, Long COVID brain fog — is out. If your clinical team documents a qualifying cause but the ICD-10 code tells a different story, expect a denial.
For cognitive rehabilitation billing, documentation completeness drives payment. You need the neuropsychological test results in the file, a qualifying diagnosis, and evidence of a psychiatric or psychological evaluation before you submit CPT 97129 or +97130. Prior authorization requirements vary by plan, so check benefit terms before the first session — not after.
One exception worth noting: Aetna covers cognitive rehabilitation for encephalopathy due to HIV (ICD-10 B20) when the member meets all five criteria above. That's a carve-out from the broader HIV-related cognitive decline exclusion. Document it clearly.
Aetna Cognitive Rehabilitation Exclusions and Non-Covered Indications
Aetna's exclusion list for cognitive rehabilitation is long and specific. This is where most claim denials happen — billing for a service the policy has explicitly ruled out.
Psychiatric and behavioral diagnoses are not covered. ADHD, bipolar disorder, depression, schizophrenia, social phobia, substance use disorders, and autism spectrum disorder all fall outside this coverage policy.
Neurological conditions are also largely excluded. Dementia from Alzheimer's disease, Parkinson's disease, and HIV (except the carve-out above) are experimental. So is cognitive decline in multiple sclerosis and COPD. Cerebral palsy, intellectual disability, learning disabilities, and epilepsy are not covered indications.
Mild TBI gets its own exclusion. Aetna separates mild TBI — including sports-related concussion — from moderate to severe TBI. If a patient presents with postconcussion syndrome (ICD-10 F07.81), cognitive rehab is not covered. This matters for practices treating athletes or patients following minor head trauma.
Long COVID is explicitly excluded. Aetna lists "Long COVID / COVID brain fog" as experimental and unproven. Don't bill CPT 97129 for these patients under an Aetna plan.
Technology-based programs are not covered. Four codes are flat-out excluded regardless of clinical rationale:
| # | Excluded Procedure |
|---|---|
| 1 | CPT 0770T — Virtual reality therapy for acquired cognitive disorders |
| 2 | CPT 0615T / 1010T — EyeBox and eye movement analysis for mild TBI or concussion |
| 3 | CPT 0570U — GFAP and ubiquitin carboxy-terminal hydrolase (UCH-L1) biomarker analysis for TBI |
| 4 | HCPCS E0732 / A4596 — Cranial electrotherapy stimulation systems and supplies |
| 5 | HCPCS S9056 — Coma stimulation per diem |
Coma stimulation programs — sometimes billed as "Responsiveness Program," "coma arousal therapy," or "sensory stimulation" — are also excluded under HCPCS S9056. Combined motor and cognitive rehabilitation for mild cognitive impairment (MCI) does not qualify either.
If you're billing transcranial electrical stimulation as a supplement to post-stroke cognitive rehab, stop. Aetna considers it experimental.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Moderate to severe TBI | Covered | CPT 97129, +97130, 97537 | All 5 medical necessity criteria must be met |
| Stroke | Covered | CPT 97129, +97130, 97537 | All 5 criteria required; psychiatric/psych eval required |
| Brain surgery | Covered | CPT 97129, +97130, 97537 | All 5 criteria required |
| Encephalopathy (non-HIV) | Covered | CPT 97129, +97130, 97537 | Includes toxic, anoxic, and other encephalopathy |
| Encephalopathy due to HIV (B20) | Covered | CPT 97129, +97130, 97537 | Explicit carve-out; all 5 criteria still required |
| Mild TBI / concussion | Experimental/Not Covered | — | Includes sports-related concussion, F07.81 postconcussion syndrome |
| Dementia (Alzheimer's, Parkinson's, HIV) | Experimental/Not Covered | — | HIV cognitive rehab covered only for encephalopathy, not dementia |
| Multiple sclerosis (cognitive decline) | Experimental/Not Covered | — | Includes memory deficit in MS |
| ADHD, depression, bipolar, schizophrenia, SUD, ASD | Experimental/Not Covered | — | All behavioral/psychiatric diagnoses excluded |
| Long COVID / COVID brain fog | Experimental/Not Covered | — | Explicitly listed as unproven |
| Cerebral palsy | Experimental/Not Covered | — | All CP diagnosis codes excluded |
| Epilepsy / seizure disorders | Experimental/Not Covered | — | G40 range not a qualifying cause |
| Mild cognitive impairment (MCI) | Experimental/Not Covered | G31.84 | Combined motor + cognitive rehab for MCI excluded |
| Coma stimulation | Experimental/Not Covered | HCPCS S9056 | "Responsiveness Program," sensory stimulation all excluded |
| Virtual reality therapy | Experimental/Not Covered | CPT 0770T | Excluded for stroke, TBI, and neurodegenerative diseases |
| Cranial electrotherapy stimulation | Experimental/Not Covered | HCPCS E0732, A4596 | Equipment and supplies not covered |
| EyeBox / eye movement analysis | Experimental/Not Covered | CPT 0615T, 1010T | Excluded for mild TBI diagnosis |
| TBI biomarker test (GFAP/UCH-L1) | Experimental/Not Covered | CPT 0570U | Not covered for concussion or brain injury evaluation |
| Wernicke encephalopathy | Experimental/Not Covered | ICD-10 E51.2 | Listed under excluded indications |
Aetna Cognitive Rehabilitation Billing Guidelines and Action Items 2026
| # | Action Item |
|---|---|
| 1 | Audit your diagnosis coding before February 27, 2026. Any active cognitive rehab case billed to Aetna needs a qualifying diagnosis — moderate to severe TBI, stroke, brain surgery, or encephalopathy. Pull your active cases now. Remap anything coded to mild TBI (including F07.81), dementia, MS, or ADHD. Those claims will deny. |
| 2 | Confirm all five medical necessity criteria are documented in the patient record. Neuropsychological testing results, a qualifying neurological cause, a psychiatrist or psychologist evaluation, active participation status, and a documented expectation of significant improvement — each one must be in the chart before you bill CPT 97129 or +97130. One missing element is a denial waiting to happen. |
| 3 | Check Aetna plan benefits for outpatient cognitive rehab coverage limits. Aetna applies the same benefit plan terms and limitations used for physical and occupational therapy to outpatient cognitive rehabilitation. That means visit limits, cost-sharing, and authorization requirements may apply. Verify this before the first session, not the tenth. |
| 4 | Remove CPT 0770T, 0615T, 0570U, and 1010T from any cognitive rehab charge capture templates. These codes are explicitly not covered under CPB 0214. If your EHR includes them in standard cognitive rehab order sets or billing macros, pull them out now. Billing these codes generates denials that are hard to overturn because the policy exclusion is explicit. |
| 5 | Verify HIV-related cases carefully. Aetna covers cognitive rehab for encephalopathy due to HIV (B20) when all five criteria are met. It does not cover HIV-associated dementia under this policy. The distinction is encephalopathy vs. dementia — and it's a real distinction in the ICD-10 coding. If you see B20 cases, make sure the documentation and diagnosis support encephalopathy, not dementia, before billing. |
| 6 | Track session limits for specific deficit types. The policy includes guidance on expected session volumes: visuo-spatial deficits typically involve 20 one-hour sessions over four weeks. Language and communication deficits typically run 8 hours per week, starting at 4 weeks post-onset and continuing up to 48 weeks. These aren't hard caps, but they signal what Aetna considers reasonable. Going significantly beyond these ranges without strong documentation of ongoing progress raises utilization review risk. |
| 7 | If your practice uses virtual reality or transcranial stimulation adjuncts, bill them separately and flag for review. CPT 0770T and transcranial electrical stimulation are excluded for cognitive indications under this coverage policy. Adding them to a cognitive rehab claim won't generate reimbursement — it will generate a denial that may trigger review of the entire claim. If you're not sure how your tech-assisted services map to this policy, talk to your compliance officer before the effective date. |
| 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 Cognitive Rehabilitation Under CPB 0214
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 97129 | CPT | Therapeutic interventions focused on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, visual processing) |
| +97130 | CPT | Each additional 15 minutes (add-on to 97129) |
| 97537 | CPT | Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities) |
Not Covered / Experimental CPT Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0570U | CPT | Neurology (TBI) — analysis of GFAP and UCH-L1 | Not covered for indications listed in CPB 0214 |
| 0615T | CPT | Eye movement analysis test without spatial calibration | Not covered for indications listed in CPB 0214 |
| 0770T | CPT | Virtual reality technology to assist therapy (add-on) | Not covered for indications listed in CPB 0214 |
| 1010T | CPT | Computerized ophthalmic analysis of monocular eye movements using retinal-based eye-tracking without spatial calibration | Not covered for indications listed in CPB 0214 |
Not Covered HCPCS Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| A4596 | HCPCS | Cranial electrotherapy stimulation (CES) system supplies and accessories, per month | Not covered for indications listed in CPB 0214 |
| E0732 | HCPCS | Cranial electrotherapy stimulation (CES) system, any type | Not covered for indications listed in CPB 0214 |
| S9056 | HCPCS | Coma stimulation per diem | Not covered for indications listed in CPB 0214 |
Key ICD-10-CM Diagnosis Codes
| Code | Description | Coverage Status |
|---|---|---|
| B20 | HIV disease | Covered (encephalopathy only; dementia excluded) |
| E51.2 | Wernicke's encephalopathy | Not covered |
| F07.81 | Postconcussion syndrome | Not covered (mild TBI exclusion) |
| G31.84 | Mild cognitive impairment of uncertain or unknown etiology | Not covered |
| G80.0–G80.9 | Cerebral palsy | Not covered |
| G92.0–G92.9 | Toxic encephalopathy | Covered (when all 5 criteria met) |
| G93.1 | Anoxic brain damage, not elsewhere classified | Covered (when all 5 criteria met) |
| G93.40–G93.49 | Other and unspecified encephalopathy | Covered (when all 5 criteria met) |
| G35.A–G35.D | Multiple sclerosis | Not covered |
| G30.0–G30.9 | Alzheimer's disease | Not covered |
| G20.A1–G20.C | Parkinson's disease | Not covered |
| G40.001–G40.919 | Epilepsy and recurrent seizures | Not covered |
| I63.0–I63.5 | Cerebral infarction (stroke) | Covered (when all 5 criteria met) |
| I60.00–I62.9 | Nontraumatic subarachnoid and intracerebral hemorrhage | Covered (when all 5 criteria met) |
The full ICD-10 list under CPB 0214 includes 539 codes. The table above highlights the most clinically significant covered and excluded diagnosis codes. Review the full policy at PayerPolicy.org for the complete code set.
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