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

Aetna modified CPB 0426 for ADHD assessment and treatment, effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its ADHD coverage policy under CPB 0426 Aetna system, clarifying medical necessity criteria for evaluation services and drawing sharper lines around what testing gets covered. The policy covers a wide range of CPT codes — from psychiatric diagnostic evaluations (90791, 90792) to neuropsychological testing services (96132, 96133) — but its exclusions on psychological and neuropsychological testing for uncomplicated ADHD cases are where most claim denial risk lives. If your practice bills for ADHD evaluation services, audit your charge capture before September 26, 2025.

Quick-Reference Table

Aetna ADHD Coverage Criteria and Medical Necessity Requirements 2025

The Aetna ADHD coverage policy under CPB 0426 defines exactly which evaluation services clear the medical necessity bar. Get this wrong and you're looking at denials on services you assumed were routine.

For assessment, Aetna considers these services medically necessary: a complete psychiatric evaluation for adults (CPT 90791, 90792), EEG or neurological consult when focal signs suggest a seizure disorder or degenerative neurological condition, and a medical evaluation including complete history and physical. Lab work — CBC, liver function tests, and blood lead levels for at-risk individuals — also qualifies. Thyroid hormone levels are covered when the patient shows clinical signs of hyperthyroidism such as tachycardia, goiter, tremor, or unexplained weight loss.

Before starting stimulant medication therapy, Aetna requires laboratory evaluation (CBC, LFTs) and cardiac screening with an ECG if indicated. Document those pre-treatment labs and the ECG decision clearly. Missing that documentation is a straightforward path to a denied claim.

Parent/child interviews, or adult patient interviews, qualify when they use DSM-5 criteria. These can include evaluation of comorbid psychiatric disorders and review of family and social history. This is standard for most practices, but the DSM-5 anchor matters — document it explicitly.

Regarding prior authorization: this policy does not explicitly enumerate prior auth requirements in the summary, but behavioral health services under Aetna almost always carry prior authorization triggers at the plan level. Check individual benefit plans before scheduling neuropsychological testing or extended psychiatric evaluations. The reimbursement risk is highest there.

Aetna ADHD Testing Exclusions and Non-Covered Indications

This is where the policy gets expensive if you're not paying attention.

Neuropsychological testing (CPT 96132, 96133, 96136, 96137) is not medically necessary for uncomplicated ADHD cases. Psychological testing is not medically necessary for children with uncomplicated ADHD. Aetna draws a clear line here. "Uncomplicated" means no neurological comorbidities, no post-trauma history, no seizures.

Testing is covered in two specific situations. First, neurologically complicated cases — post head trauma, seizures — qualify for neuropsychological testing. Second, when a clinician cannot distinguish ADHD from a learning disability or language/communication disorder after history and examination, neuropsychological testing becomes medically necessary. The key phrase is "remains unclear after history and examination." The standard workup has to come first.

Testing done solely for educational purposes faces a separate problem. Many Aetna benefit plans specifically exclude educational testing from coverage. This is a plan-level exclusion, not a clinical criteria issue, so checking the member's benefit plan description is not optional. Check it every time.

The imaging codes in this policy — CT head (70450–70470), MRI brain (70551–70553), functional MRI (70554, 70555), PET brain (78608, 78609), and MR spectroscopy (76390) — fall into the non-covered group for routine ADHD evaluation. These are listed under the EEG theta/beta power ratio and related experimental groupings, meaning Aetna considers neuroimaging for ADHD diagnosis investigational. Don't bill these without a separate clinical justification that goes beyond the ADHD diagnosis.

The genetic testing codes (81171, 81172, 81401, 81404) and the specialty lab codes for allergen IgG (86001), immunoglobulins (82784, 82787), minerals like magnesium (83735), zinc (84630), and iron (83540, 83550) are also in the experimental/not-covered group. These are often ordered as part of integrative or functional medicine ADHD workups. Aetna does not cover them for this indication.

Coverage Indications at a Glance

Aetna ADHD Billing Guidelines and Action Items 2025

If your practice has mixed payer volume and you're unsure how this update intersects with your documentation workflows, talk to your compliance officer before the September 26, 2025 effective date.

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

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes

Note: The full policy lists 167 CPT codes and 33 HCPCS codes. Review the complete CPB 0426 source document at app.payerpolicy.org/p/aetna/0426 for the remaining codes not shown here.