ModifiedAmbetter NevadaPolicy CP.BH.124

Clinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment

Defines medical necessity, non-coverage, and coding implications for assessment and treatment services for attention deficit hyperactivity disorder (ADHD) for members of Centene Advanced Behavioral Health and affiliated health plans.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment

Policy CodePolicy CP.BH.124

Change TypeMaterial revisions to coverage criteria, coding lists, and exclusions (multiple additions/removals)

Effective Date

Next Review Date

Key ActionDocument a complete medical evaluation per DSM-5 TR including history, interview, collateral information and indicated labs before stimulant therapy.

SourceLink

POLICY UPDATE CHANGES

Replaced 'Actometer' with 'Actigraphy' in criteria II.A.1.

Added 'Acoustic reflex testing' to criteria I.A.2.

Reworded 'Triiodothyronine T3 levels in the blood' as 'Measures of thyroid hormones' and removed T3 specific listing.

Removed magnetic resonance imaging, brain functional MRI from I.A.12 because captured under I.A.16 (MRI) and added 'brain mapping' to brain imaging in I.A.16.

Removed neurofunctional testing selection and administration during noninvasive imaging functional brain mapping (I.A.14 removed).

Removed 'neuropsychological testing' from the insufficient evidence list and removed corresponding codes.

Added a policy statement that interventions strictly educational in nature are not medically necessary (e.g., classroom environmental manipulation, academic skills training).

Replaced instances of dashes with the word 'to' in CPT description lists and reviewed coding.

Added multiple codes as not medically necessary when billed with a sole diagnosis of ADHD (list includes 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036).

Added 'Application of modality (e.g. hot or cold packs, traction, mechanical, electrical stimulation (unattended), vasopneumatic devices, paraffin bath, whirlpool, diathermy (eg, microwave), infrared, ultraviolet, electrical stimulation (manual), iontophoresis, contrast baths, ultrasound, hubbard tank)' to II.B.2.

Specifically listed 'EndeavorRx®' in criteria point II.B.19.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria — ADHD Assessment and Treatment

Medically necessary assessment services

Covered when ALL of the following are met for assessment and treatment of ADHD

Assessment elements: Complete medical evaluation with history and physical examination; parent/child interview or patient interview (adults) per DSM-5 TR; collection of collateral information (eg, Vanderbilt or Conners); complete psychiatric evaluation or other services by a psychiatrist, psychologist, or other behavioral health professional; laboratory evaluation prior to stimulant medication therapy including CBC, liver function tests, toxicology screen if drug use is suspected, and cardiac evaluation/ECG if clinically indicated; measurement of thyroid hormone levels if clinical signs of hyperthyroidism; assessment of comorbid behavioral health and/or medical diagnoses and associated symptoms; other services necessary to meet DSM-5 TR diagnostic criteria.

Medically necessary treatment services

Covered treatment services include

Treatment modalities: Pharmacotherapy; behavioral modification; treatment of comorbid behavioral health and/or medical diagnoses and associated symptoms; ongoing assessment and application of standardized scales to assess treatment benefit; other services for treatment when not otherwise excluded.

Insufficient evidence / not medically necessary interventions

Not supported/insufficient evidence (considered not medically necessary or excluded) for assessment or treatment

Unsupported assessments: Assessments considered insufficient evidence or investigational include: actigraphy; acoustic reflex testing; AFF2 gene testing; assessment of serum lipid profiles; computerized EEG; computerized tests of attention and vigilance; education and achievement testing; electronystagmography without relevant symptoms; evaluation of iron status (serum iron/ferritin); event-related potentials; functional near-infrared spectroscopy; hair analysis; IgG blood tests; peripheral BDNF measurement; measurement of zinc; neuroimaging (CT, MRI including diffusion tensor imaging, MRS, PET, SPECT) including functional brain mapping; neuropsychiatric EEG-based assessment aids; pharmacogenetic tools; otoacoustic emissions without signs of hearing loss; Quotient system; SNAP25 testing; transcranial magnetic stimulation—evoked measures as marker of ADHD symptoms; tympanometry in absence of hearing loss; and related laboratory/genetic tests.

Unsupported treatments: Treatments considered insufficient evidence or not medically necessary include: acupuncture/acupressure; application of physical modalities (hot/cold packs, traction, mechanical, electrical stimulation unattended, vasopneumatic devices, paraffin bath, whirlpool, diathermy, infrared, ultraviolet, manual electrical stimulation, iontophoresis, contrast baths, ultrasound, hubbard tank); anticandida/antifungal agents for ADHD; anti-motion sickness medications for ADHD; auditory integration therapy; applied kinesiology; brain integration; cannabidiol oil; chelation; chiropractic manipulation; cognitive rehabilitation/training and computerized working memory training; deep pressure sensory vests; dietary therapies (eg, Feingold diet); Dore/DDAT; EEG biofeedback/neurobiofeedback; external trigeminal nerve stimulation (eTNS); herbal remedies; homeopathy; intensive behavioral intervention programs (when not evidence-based medical treatment); megavitamin therapy; metronome training; mindfulness (listed as investigational/insufficient in revisions); mineral supplementation; music therapy; optometric vision training/vision therapy; certain psychopharmaceuticals unless comorbid conditions justify use; Reboxetine; sensory integration therapy; supportive counseling (listed investigational); The Good Vibrations device; Neuro Emotional Technique; therapeutic eurythmy; transcranial magnetic stimulation/cranial electric stimulation; Vayarin; and others enumerated in the policy.

High-level coverage and investigational stance

Policy contains multiple sections clarifying medically necessary assessments and those considered insufficient evidence or not medically necessary.

Assessment Documentation and Clinical Indication: Assessment should include collection of collateral information and toxicology screen when indicated; ECG is to be performed only if clinically indicated (eg, family or personal history of cardiovascular disease or congenital heart disease).

Per revisions adding these as explicit expectations.

Treatments/Assessments Considered Insufficient Evidence/Investigational: Policy lists multiple assessments and treatments as insufficient evidence or investigational (eg, pharmacogenetic tools; cannabidiol oil; cognitive training; external trigeminal nerve stimulation; mindfulness; supportive counseling) and documents coding updates and annual reviews reflecting these positions.

See investigational/insufficient evidence section and revision history.

Not medically necessary: Educational-only interventions

Policy statements and criteria revisions impacting coverage decisions include:

Educational interventions not covered: Interventions that are strictly educational in nature (eg, classroom environmental manipulation, academic skills training) are not medically necessary because they are not considered medical interventions.

New explicit policy statement added in revisions.

Revised diagnostic/testing items

Specific testing, imaging and modality items were revised; some items removed from insufficient evidence lists and some modalities enumerated for exclusion when billed with sole ADHD diagnosis.

Imaging/testing coding changes: Replaced 'Actometer' with 'Actigraphy'; added 'Acoustic reflex testing' to assessment listings; removed separate functional MRI listing and consolidated brain mapping under MRI; removed neurofunctional testing selection/administration during noninvasive imaging functional brain mapping; measures of thyroid hormones listed rather than T3 alone; evaluation of iron status (serum iron/ferritin) noted in revision history as added to not medically necessary in some versions; coding lists updated accordingly.

Edits reflected in revision history and code tables.

Interventions that are strictly educational in nature (for example, classroom environmental manipulation or academic skills training) are not medically necessary because they are not considered medical interventions. This policy statement clarifies that educational-only approaches should not be billed or authorized as medical treatment for ADHD.

Consistent with the revised policy language, any service that is solely educational — such as classroom modifications or academic skills instruction — is explicitly excluded from medical coverage for ADHD. Such interventions do not meet the definition of a medical service and therefore are not medically necessary under this policy.

The policy reiterates that interventions that are purely educational in purpose (e.g., classroom environmental manipulation, academic skills training) are excluded from coverage as they are not medical treatments. Providers should ensure services billed as medical care for ADHD have a documented medical rationale beyond educational strategies.

The policy enumerates numerous assessments and treatment modalities that are considered investigational or have insufficient evidence to support medical necessity for ADHD. Examples of listed assessments include actigraphy, acoustic reflex testing, AFF2 gene testing, computerized EEG, computerized attention tests, otoacoustic emissions (without hearing loss), measurement of peripheral BDNF, neuroimaging (CT, MRI, PET, SPECT, functional brain mapping), and evaluation of thyroid hormones unless clinical signs of hyperthyroidism are present. Treatment modalities identified as not medically necessary or lacking evidence include acupuncture, auditory integration therapy, cannabidiol oil, chelation, chiropractic manipulation, computerized cognitive training, EEG biofeedback/neurobiofeedback, external trigeminal nerve stimulation (eTNS), intensive behavioral programs, megavitamin therapy, mindfulness, vision therapy, transcranial magnetic stimulation / cranial electrical stimulation, and many others listed in the policy. The policy also notes alignment of the investigational list with AAP and SDBP guideline updates.

The policy identifies numerous procedure and laboratory codes that are considered not medically necessary when billed solely with a diagnosis of ADHD. These include a broad set of CPT codes for neuroimaging and advanced diagnostics (for example, CT and MRI codes) and HCPCS codes such as G0176, P2031, and S8040, among others added in recent revisions. Claims using these codes with only an ADHD diagnosis may be subject to denial.

Evaluation of iron status for ADHD assessment (for example, measurement of serum iron and ferritin) has been added to the list of assessments considered not medically necessary when performed solely for ADHD evaluation. This change is reflected in the assessment section and corresponding code updates.

The policy enumerates specific procedure and laboratory codes that are identified as not medically necessary when billed with a sole diagnosis of ADHD. Examples added or highlighted in revisions include imaging and diagnostic codes such as 70496, 70554, 70555, 78610; thyroid and laboratory related codes such as 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481; audiology codes such as 92568, 92569, 92570; and modality/application codes such as 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032–97036. HCPCS examples include G0176, P2031, S8040. Providers should review the full code lists in the policy before billing ADHD as the sole diagnosis.

Coding — CPT, HCPCS, and Diagnosis Codes

CPT/other codes considered not medically necessary when billed with a sole diagnosis of ADHDmixedNot Covered

70450	Computed tomography, head or brain; without contrast material.
70460	Computed tomography, head or brain; with contrast material(s).
70470	Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections.
70496	Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing.
70551	Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material.
70552	Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s).
70553	Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences.
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.
70555	Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing.
76390	Magnetic resonance spectroscopy.

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Covered/Listed CPT Codes and DescriptionsCPT

92587	Distortion product evoked otoacoustic emissions; limited evaluation or transient evoked otoacoustic emissions, with interpretation and report
92588	Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation, with interpretation and report
92650	Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis
92651	Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report
92652	Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report
93000	Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
93005	Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report
93010	Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
95803	Actigraphy testing recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)

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HCPCS/CPT codes considered not medically necessary when billed with a sole diagnosis of ADHDmixedNot Covered

G0176	Activity therapy (music, dance, art or play therapies) related to treatment of disabling mental health problems, per session
P2031	Hair analysis (excluding arsenic)
S8040	Topographic brain mapping
70496	Unlisted CT/MR code (listed as not medically necessary when billed with sole ADHD)
70554	CT/MR related code listed as not medically necessary with sole ADHD
70555	CT/MR related code listed as not medically necessary with sole ADHD
78610	Pulmonary/brain flow code listed as not medically necessary with sole ADHD
84436	Thyroid lab code listed as not medically necessary with sole ADHD
84437	Thyroid lab code listed as not medically necessary with sole ADHD
84439	Thyroid lab code listed as not medically necessary with sole ADHD

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ICD-10-CM Diagnosis Codes that Support Medical NecessityICD-10Covered

F90.0

Attention-deficit hyperactivity disorders

Codes listed as not medically necessary when billed with sole ADHD diagnosismixedNot Covered

70496
70554
70555
78610
84436
84437
84439
84442
84443
84445

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Provider Actions — Documentation, Billing, and Denial Risk

Denial Risk

Not Medically Necessary Codes When Sole ADHD Diagnosis

Do not bill listed imaging, laboratory, neurodiagnostic, therapeutic modality, or other procedure codes with a sole diagnosis of ADHD — these services are considered not medically necessary when ADHD is the only diagnosis and may be denied. When such services are clinically indicated, document a complete medical evaluation, clinical rationale linking the service to patient-specific signs/symptoms, and include applicable collateral information or prior authorization as required.

Not medically necessary when billed with sole diagnosis of ADHD: brain CT/MRI/functional MRI/CT angiography (e.g., 70450, 70460, 70470, 70496, 70551-70555, 70554-70555)
Not medically necessary when billed with sole diagnosis of ADHD: advanced brain imaging and mapping (e.g., 76390, 78803, S8040)
Not medically necessary when billed with sole diagnosis of ADHD: PET/SPECT and related brain imaging (e.g., 78600-78610, 78803)
Not medically necessary when billed with sole diagnosis of ADHD: extensive laboratory/genetic testing including lipid panel and specialized assays (e.g., 80061, 82465, 83718-83722, 81171, 81172, 81229, 82365, 82728, 82784, 82787)
Not medically necessary when billed with sole diagnosis of ADHD: thyroid and related hormone tests unless clinically indicated (e.g., 84436-84445, 84478-84481)
Not medically necessary when billed with sole diagnosis of ADHD: auditory/vestibular and related neurodiagnostic testing when solely for ADHD (e.g., 92540-92570, 92587-92588, 92650-92653, 95705-95710, 95812-95813, 95816, 95819, 95803)

Treatment Modalities — Behavioral, Pharmacologic, Digital, and Physical

Behavioral interventions and pharmacotherapy

Behavioral interventions and pharmacotherapy: AAP age-based recommendations: preschool (4-6 years) — evidence-based behavioral Parent Training in Behavior Management and/or classroom interventions first-line (methylphenidate if ineffective); elementary/middle (6-12 years) — combination of FDA-approved medications and PTBM/classroom interventions; adolescents (12-18 years) — FDA-approved medications plus evidence-based training or behavioral interventions. Policy aligns with AAP/SDBP guidance and supports psychosocial treatments as foundational for complex ADHD.

Medication management, CBT, behavior interventions

Medication management, CBT, behavior interventions: Includes medication management (stimulant and selected nonstimulant agents per evidence) and behaviorally based interventions; ongoing assessment with standardized scales to monitor benefit; CBT noted as treatment modality for adults in guideline discussion.

Investigational behavioral health modalities

Level of Care — Outpatient Criteria

Definitions and Terminology

ADHD (DSM‑aligned definition)

DefinitionAttention‑Deficit/Hyperactivity Disorder (ADHD) is characterized by symptoms of inattention, hyperactivity, and impulsivity that have persisted for at least six months, are maladaptive and inconsistent with developmental level, and are diagnosed clinically using DSM‑5/DSM‑5‑TR criteria.

Core featuresSymptoms include inattention, hyperactivity, and impulsivity that affect cognitive, academic, emotional, and social functioning across the lifespan.

Duration requirementSymptoms must have continued for at least six months and be inconsistent with developmental level.

Diagnostic approachThere is no single test; diagnosis is established by clinical assessment using DSM‑5/DSM‑5‑TR criteria.

DSM‑5 TR–based assessment elements

Required assessment components

Background — ADHD Overview

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity that persist for at least six months and are inconsistent with developmental level. Diagnosis is clinical and relies on a comprehensive evaluation using DSM-5 (DSM-5‑TR) criteria, including a medical history and physical examination, patient and/or parent interview, and collection of collateral information (for example, Vanderbilt or Conners rating scales). Assessment should also consider comorbid medical and behavioral health conditions and include guideline-directed laboratory or cardiac evaluation only when clinically indicated.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment

Policy CodePolicy CP.BH.124

Change TypeMaterial revisions to coverage criteria, coding lists, and exclusions (multiple additions/removals)

Effective Date

Next Review Date

Key ActionDocument a complete medical evaluation per DSM-5 TR including history, interview, collateral information and indicated labs before stimulant therapy.

SourceLink

On This Page

Documentation Required

Assessment Documentation Expectations

When ordering assessments for ADHD, document a complete medical evaluation including history and physical, DSM-5 TR–based interview (patient or parent/child as appropriate), collection of collateral information (eg, Vanderbilt or Conners scales), and psychiatric evaluation when provided by a behavioral health professional. Include laboratory evaluation prior to stimulant therapy when indicated (CBC, liver function tests, toxicology if substance use suspected) and measure thyroid function when clinical signs suggest thyroid disease.

Document the clinical indication/rationale for any imaging, advanced testing, genetic or laboratory studies ordered for ADHD patients
Include collateral standardized rating scales and documentation of functional impairment and comorbidities
Toxicology screening should be performed if drug use is suspected and documented
ECG should be obtained only if clinically indicated (personal or family cardiac history or congenital heart disease) — if obtained, document indication and interpretation

Documentation Required

Documentation Expectations

Providers should document clinical rationale when ordering imaging, laboratory, genetic, neurodiagnostic, or modality-based interventions. Educational or purely classroom interventions are not considered medical treatments and are not covered. When a listed service is clinically indicated despite ADHD being the primary diagnosis, include specific signs/symptoms, exam findings, prior conservative management, and any collateral data supporting medical necessity; prior authorization may be required for some services.

Educational interventions (eg, classroom environmental manipulation, academic skills training) are not medically necessary as medical interventions
For services that appear on the not-medically-necessary lists, include documentation tying the service to non-ADHD diagnoses or specific clinical findings to justify coverage
Prior authorization: check plan requirements for services listed as denial risk — furnishing documentation at time of request reduces denials

Note

Age-Based Treatment Sequencing

Follow age-based treatment sequencing per AAP guidance: psychosocial/behavioral interventions are first-line for preschool-aged children; combined behavioral and medication approaches for school-aged children; and medication plus evidence-based behavioral interventions for adolescents and adults as appropriate. Use shared decision-making and incorporate educational supports (IEP/504) when applicable.

Preschool (4–6 years): evidence-based parent training in behavior management (PTBM) and/or classroom interventions first; consider methylphenidate only if nonpharmacologic measures fail
Elementary/middle (6–12 years): combine FDA‑approved medications with PTBM and classroom interventions; consider educational supports such as IEP
Adolescents (12–18 years) and adults: FDA‑approved medications are indicated with evidence‑based behavioral therapies; plan transition to adult care as part of chronic care model

Billing Rule

Provider Action — Billing and Denial Risk

Codes listed as not medically necessary when billed with a sole diagnosis of ADHD may lead to claim denial. If these services are clinically warranted for comorbid conditions or specific signs/symptoms, document the alternative/secondary diagnosis and clinical justification clearly on the claim and in the medical record. Prior authorization may be required for certain services; confirm with Ambetter Nevada plan requirements.

When submitting claims for any code on the not-medically-necessary lists, include supporting diagnosis codes beyond ADHD or documented clinical indication to avoid automatic denial
Examples of HCPCS codes that may be denied if billed solely for ADHD: G0176, P2031, S8040
Examples of CPT codes that may be denied if billed solely for ADHD: neuroimaging (70450–70555 series), advanced diagnostics (78600–78610 series), extensive labs/genetics (80061, 81171–81172, 81229, 82465, 83718–83722, 84436–84445), neurodiagnostics (92540–92570 series, EEG codes 95705–95710, 95812–95819), ECG codes (93000, 93005, 93010)