Sensory and Auditory Integration Therapy — CPB 0256 | AETNA Coverage Update

TL;DR: Aetna modified CPB 0256 covering sensory and auditory integration therapy, effective September 26, 2025. CPT 97533 is not covered for any of the 64 listed ICD-10 diagnoses. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its sensory and auditory integration therapy coverage policy under CPB 0256 in the Aetna CPB 0256 Aetna system. This policy classifies CPT 97533 — sensory integrative techniques to enhance sensory processing and promote adaptive responses — as not covered across a broad range of pediatric behavioral, developmental, and psychiatric diagnoses. If your practice bills sensory integration therapy for patients with autism spectrum disorder, ADHD, or learning disabilities under an Aetna plan, this policy change directly affects your reimbursement.

Quick-Reference Table

Aetna Sensory Integration Therapy Coverage Criteria and Medical Necessity Requirements 2025

The core of this coverage policy is straightforward: Aetna does not consider sensory integration therapy medically necessary for the diagnoses listed in CPB 0256. That list covers 64 ICD-10 codes. It spans adjustment disorders, pervasive developmental disorders, ADHD, conduct disorders, specific learning disorders, childhood emotional disorders, Fragile X syndrome, and developmental delay.

CPT 97533 — the primary billing code for sensory integrative techniques — sits in the "CPT codes not covered for indications listed in the CPB" group. That language is explicit. There are no carve-outs, no prior authorization pathway that unlocks coverage, and no clinical exceptions listed in the policy data.

This is a blanket non-coverage position. Aetna's stance is that sensory integration therapy lacks sufficient clinical evidence to meet medical necessity standards for these diagnoses. Whether you agree with that clinical determination doesn't matter for billing purposes. What matters is that submitting CPT 97533 against these ICD-10 codes will generate a claim denial.

If your team has been billing 97533 for patients with F84.0 (autism spectrum disorder), F90.0–F90.9 (ADHD), or any of the F81 learning disorder codes, you need to audit those claims now — before the effective date of September 26, 2025.

Aetna Sensory Integration Therapy Exclusions and Non-Covered Indications

Every indication in this policy is a non-covered indication. That's the key point. This isn't a policy where some diagnoses are covered and others are excluded. CPB 0256 functions as a categorical exclusion policy for CPT 97533.

The 64 ICD-10 codes listed span five major diagnostic categories. Each one is paired with CPT 97533 as "not covered." There is no covered column in this policy.

The diagnoses most likely to show up in your charge capture — and most likely to generate denials — include the F84 pervasive developmental disorder codes (autism spectrum disorder and related conditions), the full range of F90 ADHD codes, and F80.9 (communication disorder). These are common pediatric diagnoses in occupational therapy and behavioral health practices.

Auditory integration therapy — the other modality in this policy's title — is also not covered. The policy title names both sensory and auditory integration therapy. Your billing team should treat both as non-covered under Aetna plans.

Coverage Indications at a Glance

Aetna Sensory Integration Therapy Billing Guidelines and Action Items 2025

This policy has a hard effective date of September 26, 2025. The actions below are not suggestions.

CPT, HCPCS, and ICD-10 Codes for Sensory Integration Therapy Under CPB 0256

Not Covered CPT Codes

Key ICD-10-CM Diagnosis Codes