TL;DR: Aetna, a CVS Health company, modified CPB 0480 — its Tourette syndrome coverage policy — effective February 27, 2026. Here's what billing teams need to know before submitting claims.
This update to CPB 0480 tightens the criteria for what counts as medically necessary assessment and treatment for Tourette syndrome (TS). The policy covers a wide range of services — from EEG codes like 95812–95830 to psychotherapy codes 90832 and 90839 — but draws a hard line around a long list of experimental services. If your practice treats TS patients with Aetna coverage, this policy determines which claims get paid and which get denied.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Tourette Syndrome — CPB 0480 |
| Policy Code | CPB 0480 |
| Change Type | Modified |
| Effective Date | February 27, 2026 |
| Impact Level | Medium |
| Specialties Affected | Neurology, Psychiatry, Behavioral Health, Primary Care, Pediatrics |
| Key Action | Audit active TS claims for compliance with all five medical necessity criteria before submitting under covered CPT codes |
Aetna Tourette Syndrome Coverage Criteria and Medical Necessity Requirements 2026
Aetna's Tourette syndrome coverage policy requires that a member meet all five of the following criteria before any service qualifies as medically necessary. Miss one, and the claim is exposed to denial.
Here are the five criteria, exactly as the policy states them:
| # | Covered Indication |
|---|---|
| 1 | Both multiple motor tics and one or more vocal tics have been present at some point during the illness — though not necessarily at the same time. |
| 2 | The condition causes significant distress or marked impairment in social, occupational, or other important areas of functioning. |
| 3 | The disturbance is not due to the direct physiological effects of a substance (such as stimulants) or a general medical condition (such as Huntington's disease or post-viral encephalitis). |
| 4 | Onset occurred before age 21. |
| 5 | Tics occur many times a day (usually in bouts) almost every day or periodically, over a duration of more than one year — with no tic-free period exceeding three consecutive months during that time. |
All five must be documented in the medical record. Aetna's medical necessity language is explicit here: this is an "all of the following" policy, not an "any of the following" standard.
Once those criteria are satisfied, the following services are covered.
Assessment:
| # | Covered Indication |
|---|---|
| 1 | EEG (CPT codes 95812–95830) — but only when focal signs are present or there is a clinical suggestion of seizure disorder or a degenerative condition. Don't bill routine EEG on every TS patient. Aetna won't cover it. |
| 2 | Medical evaluation, including complete history and physical. |
| 3 | Neurological consult — again, only when focal signs or clinical concern for seizure or degeneration are present. |
Treatment:
| # | Covered Indication |
|---|---|
| 1 | Pharmacotherapies including aripiprazole (Abilify), clonazepam (Klonopin), clonidine (Catapres), fluphenazine (Prolixin), haloperidol (Haldol), pimozide (Orap), risperidone (Risperdal), tetrabenazine, and tricyclic antidepressants (for members who also have ADHD). These are covered under the pharmacy benefit — formulary restrictions may apply. Check the member's plan benefit description. |
| 2 | Psychotherapy (CPT codes 90832, 90838, 90839, 90840, and +90785 for interactive complexity) — covered when the member also exhibits anxiety and/or depression. These route through behavioral health benefits. |
One thing to flag on prior authorization: CPB 0480 does not specify prior authorization requirements. But individual plan benefit descriptions control what's required at the member level. Verify with Aetna provider services or your billing consultant before submitting if you're not certain how prior authorization applies to your patient mix.
Reimbursement for covered services depends on correct documentation of all five medical necessity criteria — not just a diagnosis code. Build that documentation requirement into your intake workflow now.
Aetna Tourette Syndrome Exclusions and Non-Covered Indications 2026
This is the section that creates the most claim denial risk. Aetna designates a substantial list of assessment and treatment services as experimental, investigational, or unproven for Tourette syndrome. These will not be reimbursed under CPB 0480.
Excluded Assessment Services:
| # | Excluded Procedure |
|---|---|
| 1 | Cognitive and motor event-related potentials |
| 2 | Computerized EEG, brain mapping, and neurometrics (see CPB 0221) |
| 3 | Genetic studies |
| 4 | Plasma or serum cytokine and T-cell measurements |
| 5 | Serum ferritin level measurement (CPT 82728) |
| 6 | MicroRNAs (miRNAs) as a biomarker |
| 7 | Neuroimaging — including CT (CPT 70450, 70460, 70470, 70472, 70473), MRI (CPT 70551, 70552, 70553, 70554, 70555), PET (CPT 78608, 78609), and SPECT (CPT 78607) |
| 8 | Quantitative susceptibility mapping of brain iron for TS diagnosis or monitoring (CPT 0648T, 0649T) |
Excluded Treatment Services:
| # | Excluded Procedure |
|---|---|
| 1 | Acupuncture (see CPB 0135) |
| 2 | Adaptive (responsive) deep brain stimulation |
| 3 | Amphetamines — unless comorbid ADHD is documented |
| 4 | Anti-glutamatergic drugs: gabapentin, lamotrigine, riluzole, topiramate |
| 5 | Baclofen |
| 6 | Bilateral stereotactic lesions of the anterior cingulate gyrus (CPT 61735) |
| 7 | Bilateral thalamic stimulation and deep brain stimulation (CPT 61863, +61864, 61867, +61868 — see CPB 0208) |
| 8 | Botox injections / chemodenervation (CPT 64612, 64616, 64617 — see CPB 0113) |
| 9 | Transcranial direct current stimulation |
| 10 | Transcranial magnetic stimulation |
| 11 | Various other investigational interventions |
The neuroimaging exclusion is the one most likely to trip up billing teams. Ordering MRI or CT to rule out other conditions is clinically common with new TS presentations. But Aetna won't cover neuroimaging under this policy. If you're billing neuroimaging for a TS patient, document clearly that the indication is something other than TS evaluation — and make sure your diagnosis coding reflects that distinction.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Medical evaluation (history & physical) | Covered | 99201–99215 | All five selection criteria must be met |
| EEG with focal signs or seizure concern | Covered | 95812–95830 | Not covered for routine TS workup without clinical indication |
| Neurological consult (focal signs present) | Covered | 99201–99215 | Only when focal signs or degenerative/seizure concern documented |
| Covered pharmacotherapies (aripiprazole, haloperidol, pimozide, etc.) | Covered | Pharmacy benefit | Formulary restrictions apply; check member plan |
| Tricyclic antidepressants | Covered | Pharmacy benefit | Only when comorbid ADHD is documented |
| Psychotherapy for comorbid anxiety/depression | Covered | 90832, 90838, 90839, 90840, +90785 | Routes through behavioral health benefit |
| Neuroimaging (CT, MRI, PET, SPECT) | Experimental | 70450, 70460, 70470, 70472, 70473, 70496, 70544, 70545, 70546, 70551, 70552, 70553, 70554, 70555, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610 | Not covered for TS assessment or monitoring; only specific codes listed in CPB 0480 are excluded |
| Deep brain stimulation | Experimental | 61863, +61864, 61867, +61868 | See CPB 0208 |
| Botox / chemodenervation | Experimental | 64612, 64616, 64617 | See CPB 0113 |
| Genetic studies | Experimental | 88245+ | Not covered for TS indication |
| Serum ferritin | Experimental | 82728 | Not covered for TS indication |
| Computerized EEG / brain mapping | Experimental | See CPB 0221 | Not covered for TS |
| MicroRNA biomarker testing | Experimental | — | No CPT listed; not covered |
| Acupuncture | Experimental | See CPB 0135 | Not covered for TS |
| Adaptive deep brain stimulation | Experimental | — | Not covered for TS |
| Anti-glutamatergic drugs (gabapentin, topiramate, etc.) | Experimental | Pharmacy benefit | Not covered for TS indication |
| Amphetamines | Experimental (with exception) | Pharmacy benefit | Covered only with documented comorbid ADHD |
| Quantitative susceptibility mapping | Experimental | 0648T, 0649T | Not covered for TS diagnosis or monitoring |
Aetna Tourette Syndrome Billing Guidelines and Action Items 2026
Here's what your team needs to do before submitting claims under CPB 0480 after the February 27, 2026 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your TS charge capture against all five medical necessity criteria. Build a documentation checklist that maps directly to the five criteria. Your clinical team needs to document tic type (motor and vocal), duration over one year, frequency (including bouts), impairment, age of onset, and the absence of substance or medical-condition causation. Missing any one of these creates denial exposure. |
| 2 | Stop billing EEG codes 95812–95830 for routine TS workup. Aetna covers EEG only when focal signs are present or there is clinical concern for seizure disorder or a degenerative condition. If that clinical justification isn't in the note, the claim will not survive review. Make sure your ordering providers document that indication explicitly. |
| 3 | Separate neuroimaging claims from TS diagnosis codes. If you're imaging a TS patient to rule out another condition, your primary diagnosis on that claim should not be the TS code. Aetna excludes specific neuroimaging codes — including CPT 70450, 70551, 78607, and 78608 — for TS assessment. Wrong diagnosis linkage is a fast path to a claim denial. |
| 4 | Route psychotherapy correctly. CPT codes 90832, 90838, 90839, 90840, and add-on +90785 go through the behavioral health benefit — not the medical benefit. Confirm the member has active behavioral health coverage and verify any applicable prior authorization requirements before the visit. Psychotherapy is only covered under this policy when the member has documented comorbid anxiety or depression. |
| 5 | Verify ADHD documentation before billing tricyclic antidepressants or amphetamines. Tricyclics are covered for TS members who also have ADHD. Amphetamines are experimental for TS unless comorbid ADHD is documented. Your pharmacy benefit claims won't reflect this distinction automatically — make sure the diagnosis coding and medical record support the comorbidity. |
| 6 | Flag the neuroimaging and DBS codes in your payer editing system. Add edits for the specific neuroimaging CPT codes listed in CPB 0480 — including 70450, 70460, 70470, 70472, 70473, 70496, 70551, 70552, 70553, 70554, 70555, 78607, 78608, 78609 — along with DBS codes 61863, +61864, 61867, and +61868 to block or alert before submission under a TS primary diagnosis. These are experimental under CPB 0480 and will generate denials. |
| 7 | Check member-level benefits before assuming clean claim status. This policy sets the coverage framework, but individual plan benefit descriptions control formulary access, behavioral health benefit availability, and prior authorization requirements. Don't assume uniform treatment across your Aetna book. |
| 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 Tourette Syndrome Under CPB 0480
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Description |
|---|---|
| +90785 | Interactive complexity (add-on to primary procedure) |
| 90832 | Psychotherapy, 30 minutes with patient and/or family member |
| 90838 | Psychotherapy, 60 minutes with patient when performed with E&M |
| 90839 | Psychotherapy for crisis; first 60 minutes |
| 90840 | Psychotherapy for crisis; each additional 30 minutes (add-on) |
| 95812 | Routine EEG |
| 95813 | Routine EEG |
| 95814 | Routine EEG |
| 95815 | Routine EEG |
| 95816 | Routine EEG |
| 95817 | Routine EEG |
| 95818 | Routine EEG |
| 95819 | Routine EEG |
| 95820 | Routine EEG |
| 95821 | Routine EEG |
| 95822 | Routine EEG |
| 95823 | Routine EEG |
| 95824 | Routine EEG |
| 95825 | Routine EEG |
| 95826 | Routine EEG |
| 95827 | Routine EEG |
| 95828 | Routine EEG |
| 95829 | Routine EEG |
| 95830 | Routine EEG |
| 99201 | E&M, office or other outpatient services |
| 99202 | E&M, office or other outpatient services |
| 99203 | E&M, office or other outpatient services |
| 99204 | E&M, office or other outpatient services |
| 99205 | E&M, office or other outpatient services |
| 99206 | E&M, office or other outpatient services |
| 99207 | E&M, office or other outpatient services |
| 99208 | E&M, office or other outpatient services |
| 99209 | E&M, office or other outpatient services |
| 99210 | E&M, office or other outpatient services |
| 99211 | E&M, office or other outpatient services |
| 99212 | E&M, office or other outpatient services |
| 99213 | E&M, office or other outpatient services |
| 99214 | E&M, office or other outpatient services |
| 99215 | E&M, office or other outpatient services |
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