Tourette Syndrome — CPB 0480 | AETNA Coverage Update

Aetna modified CPB 0480 for Tourette syndrome assessment and treatment, effective February 27, 2026. Here's what billing teams need to know.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0480 governing the Aetna Tourette syndrome coverage policy for assessment and treatment services. The change affects a wide range of CPT codes — from EEG codes 95812 through 95830, to E&M codes 99201–99215, to psychotherapy codes 90832 and 90839. If your practice sees pediatric neurology, child psychiatry, or behavioral health patients with TS, this policy update directly affects your reimbursement.

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Quick-Reference Table

Field	Detail Copy
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	Pediatric neurology, child psychiatry, behavioral health, primary care
Key Action	Audit your TS claims against all five medical necessity criteria before billing covered CPT codes

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Aetna Tourette Syndrome Coverage Criteria and Medical Necessity Requirements 2026

The Aetna Tourette syndrome coverage policy under CPB 0480 sets five criteria that all must be met before any assessment or treatment service qualifies as medically necessary. Every single one. This is a conjunctive standard — missing one criteria means the claim is exposed.

Here's what Aetna requires:

That fifth criterion is the one that trips up documentation most often. "More than one year" with no long break is a high bar. If your clinical notes don't explicitly address duration and frequency, you'll face a claim denial.

Once medical necessity is established, two categories of services become billable. For assessment, Aetna covers a complete medical history and physical examination, and EEG codes (95812–95830) — but only when focal neurological signs or clinical suspicion of seizure disorder or a degenerative condition are present. EEGs aren't routine workup tools under this policy. If you're billing 95812 or 95816 without documented focal signs, that claim is vulnerable.

For treatment, covered pharmacotherapies include aripiprazole (Abilify), clonazepam (Klonopin), clonidine (Catapres), fluphenazine (Prolixin), haloperidol (Haldol), pimozide (Orap), risperidone (Risperdal), tetrabenazine, and tricyclic antidepressants when ADHD is comorbid. Note that these are pharmacy benefit items — they're subject to formulary restrictions. Check the member's plan before assuming coverage.

Psychotherapy (CPT 90832, 90838, 90839, 90840, and add-on +90785) is covered when the member also exhibits anxiety or depression. It falls under behavioral health benefits, not medical. Your billing team should confirm which benefit bucket applies before submitting claims.

Prior authorization requirements are not explicitly stated in this policy bulletin. That doesn't mean prior auth isn't required for your member's specific plan. Check individual plan benefit descriptions before scheduling high-cost services.

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Aetna Tourette Syndrome Exclusions and Non-Covered Indications

This section is where the real billing risk lives. Aetna classifies a long list of services as experimental, investigational, or unproven for TS. Billing these will generate a claim denial.

On the assessment side, Aetna won't cover:

That neuroimaging exclusion is significant. Brain MRIs and CT scans are common in neurological workups, and it's easy to assume they'd be covered. For TS under this policy, they're not — regardless of how thorough the clinical rationale.

On the treatment side, Aetna will not cover:

If your practice offers deep brain stimulation or botulinum toxin for tic management, do not bill those services under this TS diagnosis without a clear plan. They're excluded under CPB 0480.

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Coverage Indications at a Glance

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Aetna Tourette Syndrome Billing Guidelines and Action Items 2026

The effective date for this modified policy is February 27, 2026. If you haven't reviewed your TS claims workflow against the updated CPB 0480 criteria yet, do it now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Tourette Syndrome Under CPB 0480

Covered CPT Codes (When Selection Criteria Are Met)

Other CPT Codes Related to CPB 0480

Code	Description Copy
96372	Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular

Not Covered / Experimental CPT Codes

Note: The full policy data references 145 CPT codes total. The policy source lists additional codes beyond what appears in the truncated data extract. Review the full CPB 0480 document at Aetna's policy portal to confirm all applicable codes for your practice.

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