Attention Deficit/Hyperactivity Disorder — CPB 0426 | AETNA Coverage Update

Aetna, a CVS Health company, modified CPB 0426 — its ADHD coverage policy — effective September 26, 2025. This update clarifies medical necessity criteria for assessment and treatment of attention deficit hyperactivity disorder, affecting a wide range of CPT codes including 90791, 90792, 96132, 96136, and 96158, among 167 total CPT codes under this policy.

Aetna ADHD Coverage Criteria and Medical Necessity Requirements 2025

The Aetna ADHD coverage policy under CPB 0426 lays out a specific list of assessment services Aetna considers medically necessary. Your billing team needs to know exactly which services clear the bar — and which ones don't.

For the diagnostic workup, Aetna covers a complete psychiatric evaluation for adults (CPT 90791 or 90792). It also covers a parent/child interview — or patient interview for adults — using DSM-5 criteria. That interview can include evaluation of comorbid psychiatric disorders and a review of family and social history.

Medical necessity also covers a complete medical history and physical examination. Laboratory work — CBC and liver function tests — is covered prior to starting stimulant medication. Cardiac evaluation with ECG is covered when indicated before stimulants begin. Blood lead level testing is covered for individuals with risk factors. Thyroid hormone levels are covered when the patient shows clinical signs of hyperthyroidism — things like tachycardia, diffuse goiter, weight loss, or tremor.

EEG and neurological consult are covered when focal signs or clinical findings suggest a seizure disorder or degenerative neurological condition. That's a narrower indication than some practices assume.

On the treatment side, Aetna considers both pharmacotherapy and behavioral modification medically necessary for ADHD treatment. That opens reimbursement for a range of health behavior intervention codes like 96158, 96164, 96167, and 96170.

Prior authorization requirements aren't explicitly detailed in this policy update, but given the specificity of the medical necessity criteria, expect Aetna to scrutinize claims without clear documentation. If your practice bills neuropsychological testing or brain imaging for ADHD and you're unsure how this applies to your patient population, talk to your compliance officer before the September 26, 2025 effective date.

Aetna ADHD Exclusions and Non-Covered Indications

This is where billing teams get burned. The policy is explicit about what doesn't qualify, and Aetna will deny claims that don't meet these thresholds.

Neuropsychological testing — CPT 96132 and 96133 — is not medically necessary for uncomplicated ADHD. Aetna will cover it only for neurologically complicated cases (post head trauma, seizures) or to distinguish ADHD from learning disabilities or language disorders when that distinction isn't clear after history and exam.

Psychological testing is not medically necessary for children with uncomplicated ADHD. Full stop.

Testing performed solely for educational reasons may be excluded from coverage entirely. Many Aetna benefit plans specifically exclude educational testing — check the individual benefit plan before billing CPT 96136, 96138, or 96146 in that context.

A large block of codes — brain imaging, EEG variants, genetic tests, allergen panels, micronutrient labs — fall into a separate group labeled as not covered for ADHD. These include CPT 70450–70555 (CT and MRI of the brain), 78608 (PET), 76390 (MR spectroscopy), and 0033U (pharmacogenomic testing for serotonin receptor metabolism). Billing any of these for an ADHD diagnosis without a distinct, documented clinical indication outside the ADHD evaluation will result in a claim denial.

The same applies to codes like 82784, 82787, 83735, 84630, and 86001 — immunoglobulin panels, magnesium, zinc, and allergen-specific IgG. These are listed as not covered when used as assessment tests for dietary prescriptions in ADHD management.

Coverage Indications at a Glance

Aetna ADHD Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. Here's what your billing team needs to do before claims start flowing under this updated policy.

CPT, HCPCS, and ICD-10 Codes for ADHD Under CPB 0426

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes (EEG Theta/Beta Power Ratio, Brain Imaging, Pharmacogenomics, and Related Tests)

Note: The full policy includes 167 CPT codes and additional HCPCS and ICD-10-CM codes. Review the complete CPB 0426 policy at the Aetna source for the full code list.