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Attention Deficit/Hyperactivity Disorder
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This Aetna clinical policy bulletin defines medically necessary assessment and treatment services for ADHD, lists services considered experimental/investigational or not medically necessary, and provides related coding guidance; it applies to Aetna members and providers under Aetna benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria for ADHD Assessment and Treatment
Medically Necessary Assessment and Treatment
Covered when the following services are indicated as part of ADHD assessment and management
Neuropsychological or psychological testing is not considered medically necessary for uncomplicated ADHD or when performed solely for educational reasons.
Experimental/Investigational — Assessment and Treatment
Considered experimental and investigational (not supported by peer-reviewed literature) for assessment or treatment of ADHD
These are listed explicitly as experimental/investigational for ADHD.
Medical marijuana is excluded as not FDA-approved for ADHD.
Diagnostic criteria and general coverage stance
Covered when clinical diagnostic criteria and documentation requirements are met
Supports comprehensive history, parent/teacher ratings, medical exam; see DSM-5 criteria.
Neuropsychological testing — coverage exception
Neuropsychological testing coverage logic
Neuropsychological or psychological testing performed solely for educational reasons is generally not medically necessary and may be excluded from coverage by many plans.
Noncovered or investigational treatments
Treatments lacking sufficient evidence to support coverage
Some modalities (eg, neurofeedback, working memory training, EndeavorRx, eTNS) have mixed/preliminary evidence and are described as investigational pending further high-quality research.
Coverage interpretation and clinical criteria
Evidence-based coverage considerations and clinical interpretation of reviewed items
Consider these agents cautiously when first-line treatments fail or are contraindicated and document rationale and safety monitoring.
CAM interventions may be considered adjunctive with informed consent about limited evidence.
Use adjunctive test results cautiously and only integrated with comprehensive clinical evaluation.
Pharmacogenetic testing remains investigational for routine ADHD treatment guidance.
Coverage summary for adjunctive tests and investigational treatments
Summary of coverage-oriented evidence statements from background sections
Further high-quality studies needed to clarify potential clinical utility.
Consider individualized adjunctive use in select low-responders or medication-intolerant patients with informed discussion of limited evidence.
Coverage decisions should weigh FDA authorization against limited trial data and may require appropriate patient selection and documentation.
May be considered supportive or investigational depending on evidence and individualized clinical need.
Neuropsychological or psychological testing performed solely for educational reasons may be excluded from coverage; many Aetna plans exclude educational testing and such services are usually provided by school systems, so confirm member benefit plan details. Neuropsychological testing may be considered medically necessary only in neurologically complicated cases (for example, after head trauma or in persons with seizure disorder) or when testing is needed to distinguish ADHD from learning, language, or communication disorders after history and examination. For uncomplicated ADHD, neuropsychological and psychological testing are not considered medically necessary for clinical evaluation.
Routine ancillary assessments such as EEG in the absence of focal neurologic signs, general neuroimaging, hair analysis, measurement of zinc, and computerized continuous performance or other attention-testing platforms lack sufficient evidence to support routine use for ADHD diagnosis and are described as investigational or not supported. These modalities are indicated only when clinical evaluation suggests another condition (for example, focal signs or suspected seizure disorder) that would justify such testing.
Programs and interventions marketed specifically for learning disorders or ADHD—such as the Dore program (DDAT), intensive behavioral intervention programs promoted for learning disorders, and metronome/interactive metronome training—do not have convincing, high-quality evidence of durable benefit for core ADHD symptoms. Major clinical reviews and guidelines do not list these approaches as recommended treatments, and existing studies have methodological limitations or fail to show sustained gains on primary academic or attention outcomes.
The EEG theta:beta power ratio and measures of frontal beta power should not be used to confirm an ADHD diagnosis or to replace standard clinical evaluation. Evidence reviews (AAN) found that combining theta/beta and frontal beta has relatively high sensitivity/specificity in some studies but is insufficiently accurate for routine diagnostic confirmation and carries risk of misdiagnosis; use is recommended only in research settings and not as a standalone diagnostic test.
Novel or emerging tests and biomarkers such as syntonic phototherapy, AFF2 genetic testing, and routine serotonin-receptor family genetic testing are not supported as standard diagnostic or management tools for ADHD. UpToDate and systematic-review summaries do not list these modalities as established management options, and current evidence is insufficient to support routine clinical use.
Psychotherapy interventions directed at the child (for example, play therapy) have not been shown to improve core ADHD symptoms in randomized trials and systematic reviews; benefits observed in psychotherapy tend not to transfer reliably to classroom or home settings. Psychotherapy may be appropriate when coexisting conditions (such as depression or anxiety) require treatment, but it is not supported as a primary treatment for core ADHD symptoms.
Measures derived from quantitative EEG (qEEG) or brain-network analyses—such as EEG theta/beta power ratio, frontal beta power, and similar qEEG/BNA metrics—should not replace a comprehensive clinical assessment and are not supported as sole diagnostic justification for ADHD in routine practice. Diagnostic reliance on these measures risks false-positive diagnoses and potential harm; their use is limited to research or as adjunctive information integrated into a full clinical evaluation.
Neuropsychological and psychological testing are not considered medically necessary for the routine clinical evaluation of persons with uncomplicated ADHD. Testing may be medically necessary in specific circumstances—such as neurologically complicated presentations (e.g., post–head trauma or seizure disorder) or when differentiation from learning, language, or communication disorders remains unclear after thorough history and examination—but is otherwise excluded from routine diagnostic workup.
Neuropsychological and psychological testing performed purely for educational planning or advocacy are generally not medically necessary and may be excluded from coverage because such evaluations are commonly provided through school systems; providers should verify member benefit plan language regarding educational testing exclusions.
Use of unvalidated or commercially marketed device- or exercise-based systems—such as the Quotient ADHD System, weighted vests or deep-pressure devices, the Dore program (DDAT), and similar exercise- or device-based interventions—is not supported as standalone, evidence-based treatment for ADHD. These technologies lack robust validation as primary therapies and are considered investigational or not medically necessary when used in place of guideline-recommended pharmacotherapy or behavioral modification.
Routine essential fatty acid supplementation (omega-3/omega-6) is not suggested as a standard treatment for children with ADHD. Systematic reviews and guideline summaries report inconsistent and generally limited evidence that supplementation improves core ADHD symptoms; use may be considered only as an adjunct with informed discussion of limited benefit.
Procedures and assessments lacking consistent evidence of clinical benefit—or with heterogeneous/conflicting results—include syntonic phototherapy, routine measurement of certain peripheral biomarkers solely to diagnose or manage ADHD, hair or gut microbiota profiling for routine management, and some genetic/novel biomarker tests. These are considered experimental, investigational, or not medically necessary for routine ADHD diagnosis or treatment unless supporting high-quality evidence emerges or use is within a research protocol.
Play therapy has not been proven to improve core ADHD symptoms and observed gains typically do not generalize reliably to other settings (such as classroom or home); therefore, play therapy is not supported as a primary treatment for core ADHD symptoms, but may be used to address social skills or coexisting conditions when clinically indicated.
The current evidence does not support recommending cannabis for treatment of ADHD. Systematic and scoping reviews found inconsistent findings, limited randomized data, and potential for harm; accordingly, cannabis is not recommended for individuals with ADHD.
Interventions targeting tryptophan or serotonergic precursors lack sufficient evidence for effects on core ADHD symptoms. Existing trials are heterogeneous and small, and available data do not establish tryptophan modulation as an evidence-based treatment for ADHD.
Coding Guidance and Code Lists
| 90791 | Psychiatric diagnostic evaluation. |
| 90792 | Psychiatric diagnostic evaluation with medical services. |
| 96116 | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour. |
| +96121 | each additional hour (List separately in addition to code for primary procedure). |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour. |
| +96133 | each additional hour (List separately in addition to code for primary procedure). |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes. |
| +96137 | each additional 30 minutes (List separately in addition to code for primary procedure). |
| 96138 | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes. |
| +96139 | each additional 30 minutes (List separately in addition to code for primary procedure). |
| 0033U | HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) gene analysis, common variants. |
| 0333T | Visual evoked potential, screening of visual acuity, automated. |
| 70450 | Computed tomography, head or brain; without contrast material. |
| 70460 | Computed tomography, head or brain; with contrast material(s). |
| 70470 | CT head/brain without contrast followed by contrast and further sections. |
| 70496 | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing. |
| 70551 | Magnetic resonance imaging, brain (including brain stem); without contrast material. |
| 70552 | Magnetic resonance imaging, brain; with contrast material(s). |
| 70554 | Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration. |
| 76390 | Magnetic resonance spectroscopy. |
| 90832 | Psychotherapy, 30 minutes with patient and/or family member. |
| 90834 | Psychotherapy, 45 minutes with patient and/or family member. |
| 90837 | Psychotherapy, 60 minutes with patient and/or family member. |
| 90875 | Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy; 30 minutes. |
| 90876 | Individual psychophysiological therapy incorporating biofeedback; 45 minutes. |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses, direct (one-on-one), per 15 minutes. |
| 97810-97814 | Acupuncture. |
| 98940 | Chiropractic manipulative treatment; spinal, 1-2 regions. |
| 98941 | Chiropractic manipulative treatment; spinal, 3-4 regions. |
| 98942 | Chiropractic manipulative treatment; spinal, 5 regions. |
| 98943 | Extraspinal chiropractic manipulation. |
| 83655 | Lead level. |
| 96127 | Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument. |
| 96365-96368 | Intravenous infusion, therapy/prophylaxis/diagnosis (specify substance or drug). |
| A4541 | Monthly supplies for use of device coded at E0733. |
| A9583 | Injection, Gadofosveset Trisodium, 1 ml. |
| A9585 | Injection, gadobutrol, 0.1 ml. |
| E0733 | Transcutaneous electrical nerve stimulator for trigeminal nerve. |
| G0068 | Professional services for administration of certain infusions in the home, per 15 minutes. |
| G0129 | Occupational therapy as component of partial hospitalization program, per day. |
| G0152 | OT services in home health/hospice, each 15 minutes. |
| G0153 | Speech-language pathology services in home health/hospice, each 15 minutes. |
| G0158 | OT assistant services in home health/hospice, each 15 minutes. |
| G0159 | Physical therapist services in home health, each 15 minutes. |
| P2031 | Hair analysis (excluding arsenic). |
| S8035 | Magnetic source imaging. |
| S8040 | Topographic brain mapping. |
| S9128 | Speech therapy, in the home, per diem. |
| S9129 | Occupational therapy, in the home, per diem. |
| S9131 | Physical therapy; in the home, per diem. |
| S9152 | Speech therapy, re-evaluation. |
| S9355 | Home infusion, chelation therapy; administrative services, per diem. |
| S9445 | Patient education, not otherwise classified, non-physician provider, individual, per session. |
| S9446 | Patient education, not otherwise classified, non-physician provider, group, per session. |
| F90.0 - F90.9 | Attention-deficit hyperactivity disorder |
Provider Actions, Documentation, and Authorization Notes
EEG coverage limitation
EEG/Neurology evaluation is covered only when clinical findings suggest seizure disorder or degenerative neurologic disease. Routine EEG, EEG theta/beta ratio, WAVi/BNA or other qEEG-based testing are not supported as standalone diagnostic tools for ADHD and should not replace a comprehensive clinical evaluation.
- EEG or neurology consult indicated only with focal signs or clinical suspicion of seizure/degenerative disorder.
- EEG theta/beta ratio and frontal beta power should not be used to confirm ADHD; use only in research settings or as adjunct to full clinical exam.
Prior authorization may be required for some device/HCPCS codes
Some device and HCPCS codes associated with neurodiagnostic or device-based interventions may require prior authorization. Billing these codes for indications excluded by this policy risks denial.
- Examples of devices/code categories that may require authorization: transcutaneous electrical nerve stimulator (E0733), related supplies (A4541), and other HCPCS/HCPCS-like device codes listed in the CPB.
- Codes explicitly listed as not covered for CPB indications include A4541, A9583, A9585, E0733 and S-codes listed in CPT/HCPCS tables.
Coverage of non-first-line pharmacotherapies
Non–first-line pharmacotherapies (eg, bupropion, tricyclic antidepressants, reboxetine) may be considered in specific clinical circumstances but evidence is limited and quality low; these are generally reserved when stimulants or standard nonstimulants are ineffective, contraindicated, or not tolerated.
- Bupropion: limited low-quality evidence supports use as an alternative in adults and selected pediatric cases.
- Tricyclic antidepressants (desipramine, nortriptyline): low-to-very-low quality evidence in trials; consider for nonresponders or when stimulants contraindicated.
- Pemoline: reserved for secondary use due to hepatic risk.
Authorization for EEG-based adjunctive testing
EEG- or qEEG-based adjunctive tests (eg, NEBA System, WAVi, BNA) are not supported as replacements for clinical assessment and should be used only as adjuncts integrated into a comprehensive evaluation. Sensitivity/specificity are insufficient to permit sole reliance on these results for diagnosis.
- NEBA System: FDA-authorized as an adjunct (ages 6–17) but evidence is insufficient to support stand-alone use — integrate results with clinical exam.
- WAVi, BNA and other qEEG approaches: not supported to confirm ADHD diagnosis; risk of misdiagnosis if used alone.
Prior authorization (none specified)
No specific prior authorization rules are specified in this section beyond device/code advisories; check plan-specific prior authorization resources for requirements.
- Administrative/contact prior authorization details are not provided here — refer to payer-specific prior authorization portals or updated CPB notices.
Experimental/Investigational exclusions
The policy lists a range of assessment and treatment interventions considered experimental or investigational for ADHD; these services are not covered for the indications in this CPB.
- Assessment exclusions include: actigraphy, computerized EEG/brain mapping (qEEG), computerized continuous performance tests (eg, Gordon), WAVi brain scan, NEBA (for standalone use), polygenic risk scores, many genetic tests, and others listed in the CPB.
- Treatment exclusions include: acupuncture, chelation, applied kinesiology, cannabis, various CAM therapies and other modalities enumerated in the CPB.
Noncovered codes risk denial
Use of HCPCS/CPT codes listed as "not covered for indications listed in the CPB" for ADHD-related services may result in claim denial.
- Examples of codes at risk for denial when billed for ADHD indications: E0733 (eTNS), A4541 (monthly supplies for device e0733), A9583/A9585 (contrast injections), WAVi/EndeavorRx/no-specific-code items listed as not covered.
- Verify coding and indication prior to submission; obtain prior authorization when required.
Not applicable — document provides background/evidence
This section provides background and evidence summaries (eg, for EndeavorRx, NEBA, eTNS) but does not itself establish separate coverage rules beyond those stated elsewhere in the CPB; refer to the policy content for clinical context and to payer authorization resources for operational rules.
- EndeavorRx (AKL-T01) and other digital therapeutics have evidence in controlled trials but no standalone authorization rules are specified here.
- Background evidence should inform but not replace plan-specific coverage determinations.
Administrative disclaimer
Clinical Policy Bulletins are guidance documents to assist administration of benefits; they do not constitute a contract or provide medical advice. Treating providers are solely responsible for medical advice and treatment of members, and participating providers are independent contractors.
- CPB content may be updated and is subject to change.
- Providers must follow professional judgment and plan-specific benefit terms.
Required clinical documentation for assessment
Comprehensive clinical documentation is required to support assessment and any authorization request. Documentation should demonstrate DSM-5–consistent diagnostic criteria, functional impairment, medical evaluation, and any test results or rationale for ancillary testing.
- Required documentation: psychiatric/medical evaluation; DSM-5 symptom counts and age of onset; impairment in ≥2 settings; school/work functional assessment; medication history and response; prior treatment trials.
- Ancillary testing (CBC, LFTs, ECG) when initiating stimulant therapy and lead level when risk factors present should be documented if performed.
Iron status evaluation documentation
When iron status is evaluated, document rationale and specific laboratory findings (eg, serum ferritin). Current evidence shows lower ferritin in some ADHD cohorts but clinical significance is uncertain; use results to guide clinical management when indicated.
- If measuring iron indices, include serum ferritin and relevant contextual data (hemoglobin, clinical signs of iron deficiency).
- Evidence is mixed; testing should be targeted rather than routine.
Laboratory biomarker reporting
Studies report variable peripheral biomarker findings (ferritin, magnesium, BDNF, serum lipid patterns). These laboratory biomarkers are investigational for routine diagnosis and should be reported only when clinically indicated; include assay methods and interpretation in documentation.
- Peripheral BDNF, serum/hair magnesium, and lipid pattern measurements have inconsistent associations with ADHD; document results and how they influenced management.
- Do not use these biomarkers alone to establish an ADHD diagnosis.
Trial documentation notes
Trials of adjunctive or device therapies used for authorization (eg, digital therapeutics, eTNS) should include objective baseline measures and clearly defined outcome metrics; document trial duration, adherence, and measurable change.
- Objective baseline attention deficit examples: TOVA API ≤ -1.8 or equivalent validated measure when required by a study or product.
- Document trial length, dosing/duration (eg, EndeavorRx dosing schedule), adherence, and pre/post outcome measures (ADHD-RS, CGI, IRS, TOVA).
Treating providers are solely responsible
Providers are solely responsible for medical advice and treatment decisions for members; they are independent contractors and not agents of the payer. Follow professional standards while verifying plan-specific benefit limitations.
- Clinical decision-making and documentation obligations rest with the treating provider.
- Contact payer or utilization management for authorization/coverage questions.
Step therapy for nonstandard modalities
Step-therapy/coverage hierarchy applies to nonstandard modalities: neurofeedback may be considered adjunctive to stimulant therapy and can reduce medication dose in some studies; other nonstandard modalities (eg, CAM, Vayarin) have limited evidence and may be lower in therapy hierarchy.
- Neurofeedback: evidence supports adjunctive use to medication in select patients; consider after trials of first-line pharmacotherapy and behavioral interventions.
- Complementary/alternative therapies (omega‑3, Vayarin, elimination diets) have limited or mixed evidence and are not first-line.
No step therapy rules described for digital therapeutics
No specific step-therapy rules for digital therapeutics (eg, EndeavorRx) are specified in this CPB. Clinical use should align with product indications and integration into comprehensive treatment plans; check payer-specific policies for prior authorization or step requirements.
- EndeavorRx has age- and indication-specific evidence (8–12 years with attention issues) but CPB does not state explicit step therapy or coverage sequencing for digital therapeutics.
- Verify plan-level requirements before prescribing or billing.
Treatment Modalities and Evidence Summaries
Pharmacotherapy and Behavioral Modification
Specific drug coverage and step therapy depend on member benefit plan.
Pharmacotherapy
Effectiveness in adults is supported by trials but long-term data and generalizability are limited; coverage subject to member drug benefits.
Working memory training (Cogmed/RoboMemo)
Study limitations include small sample sizes, limited female representation, and exclusion of common comorbidities.
Neurofeedback / EEG biofeedback
May be considered as adjunctive individualized therapy; additional randomized, controlled studies are needed.
Interactive Metronome / Metronome therapy
Further research needed to clarify therapeutic role and target populations.
Restricted elimination diet (INCA Trial)
Dietary interventions should not be guided by IgG testing; findings are specific to strictly supervised protocols and require specialist oversight.
Transcranial Magnetic Stimulation (TMS) measures
Further longitudinal and replication studies are needed.
Acupuncture
Consider only as adjunctive with informed discussion about limited and low-quality evidence.
eTNS, TNS, Neurofeedback
May require prior authorization and documentation of appropriate candidate selection per plan.
Further RCTs needed to define responder profiles and standardized protocols.
Equine-assisted occupational therapy
Considered experimental/adjunctive pending further evidence.
Digital therapeutics (EndeavorRx / AKL-T01)
EndeavorRx should be considered as part of a broader therapeutic program rather than a standalone treatment.
Microbiota-focused interventions / research
Further high-quality research needed before clinical implementation.
Play therapy / psychotherapy
Psychotherapy coverage is subject to member mental health benefits and presence of comorbid conditions.
Digital therapeutic (AKL-T01 / EndeavorRx)
Additional longer-duration and pragmatic studies are needed to inform real-world use and dosing.
Pharmacotherapy — extended-release methylphenidate (adult)
Use as first-line pharmacotherapy is supported by trials, but document monitoring and consider limitations in evidence when counseling patients.
Various nonpharmacologic and device-based interventions (bibliographic evidence only)
Evidence summarized in references supports the investigational or adjunctive stance for many of these modalities pending higher-quality studies.
Definitions and Glossary
Level of Care
Visit Limits and Intervention Durations
Background and Evidence Summary
Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder diagnosed by clinical assessment using DSM-5 criteria. Key diagnostic features include persistent inattention and/or hyperactivity-impulsivity present for at least 6 months, onset of some symptoms before childhood (historically age 7, with DSM‑5 specifying before age 12), and evidence of impairment in two or more settings (for example, school and home). Clinical evaluation should include a comprehensive history, parent/teacher or collateral behavior ratings, and a medical examination; ancillary tests (laboratory studies, EEG, neuroimaging) are indicated only when the clinical assessment raises concern for alternative or comorbid medical conditions.
Policy Revision History
Policy originally became effective.
Most recent policy review completed.
Next scheduled policy review date.
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