Clinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment
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Defines medically necessary assessment and treatment services for ADHD and lists assessments/treatments considered to have insufficient evidence (not medically necessary) when requested for assessment or treatment of ADHD. Also lists CPT/HCPCS codes considered not medically necessary when billed with a sole diagnosis of ADHD and provides background and revision history.
Annual review; 'Experimental/investigational' verbiage replaced with 'there is insufficient evidence to support'.
Revised language specifying ECG can be performed only if clinically indicated.
Updated Section I.A. to include 'collection of collateral information' and 'toxicology screen.'
Added many items to the list of services considered insufficient (II.A and II.B) to reflect AAP 2019 guidelines.
Added statements about suggested first-line adult treatments and favoring medication over CBT; added to Background with no impact to criteria.
Revised description of CPT-81229, 92065, 96366, 96367 and 97814.
Approval by BH Clinical Policy Subcommittee noted with Approval Date = 02/22.
Coverage Summary
Defines medically necessary assessment and treatment services for Attention Deficit Hyperactivity Disorder (ADHD) and lists assessments and treatments considered to have insufficient evidence to support use when requested for assessment or treatment of ADHD. ADHD is described as a common neurodevelopmental/neurobehavioral disorder across ages; diagnosis requires a clinical assessment based on DSM-5 criteria, and treatment includes pharmacotherapy and behavioral interventions. Guideline statements from organizations such as the American Academy of Pediatrics and other specialty groups inform age-specific recommendations and emphasize assessment of comorbidities and functional impairment.
Medically-Necessary Criteria
Insufficient Evidence / Not Medically Necessary
Insufficient Evidence / Not Medically Necessary
There is insufficient evidence to support the following for the assessment or treatment of ADHD (may not be all-inclusive):
Assessment modalities considered insufficient
- Actometer
- AFF2 gene testing
- Assessment of serum lipid profiles
- Computerized electroencephalogram (EEG)
- Computerized Tests of Attention and Vigilance
- Education and achievement testing
- Electronystagmography in the absence of symptoms of vertigo or balance dysfunction
- Evaluation of iron status (e.g. measurement of serum iron and ferritin levels)
- Event-related potentials
- Functional near-infrared spectroscopy
- Hair analysis
- IgG blood tests
- Measurement of peripheral brain-derived neurotrophic factor
- Measurement of zinc
- Neuroimaging (e.g., CT, CAT, MRI, including diffusion tensor imaging), MRS, PET, and SPECT
- Neuropsychiatric EEG-based assessment aid system
- Neuropsychological testing for suspected uncomplicated cases of ADHD (without history of head trauma, seizures)
- Pharmacogenetic tools
- Otoacoustic emissions in the absence of signs of hearing loss
- Quotient ADHD system / test
- Synaptosomal-associated protein (SNAP) 25 gene polymorphisms testing
- Transcranial magnetic stimulation - evoked measures as a marker of ADHD symptoms
- Tympanometry in the absence of hearing loss
Treatment modalities considered insufficient
- Acupuncture/acupressure
- Anticandida albicans medication
- Anti-fungal medication
- Anti-motion sickness medication
- Auditory Integration Therapy
- Applied kinesiology
- Brain integration
- Cannabidiol oil
- Chelation
- Chiropractic manipulation
- Cognitive behavior modification
- Cognitive rehabilitation
- Cognitive training
- Computerized training on working memory
- Deep pressure sensory vest
- Dietary counseling and treatments, i.e., Feingold diet
- Dore program / dyslexia - dyspraxia attention treatment (DDAT)
- Educational intervention (e.g., classroom environmental manipulation, academic skills training, and parental training)
- Neuro Biofeedback/EEG Biofeedback
- External trigeminal nerve stimulation (eTNS)
- Herbal remedies
- Homeopathy
- Intensive behavioral intervention programs
- Megavitamin therapy
- Metronome training
- Mindfulness
- Mineral supplementation
- Music therapy
- Optometric vision training
- Psychopharmaceuticals (lithium, benzodiazepines, and SSRIs, unless the patient also exhibits anxiety and depression)
- Reboxetine
- Sensory integration therapy
- Supportive counseling
- The Good Vibrations Device
- The Neuro Emotional Technique
- Therapeutic eurythmy (movement therapy)
- Transcranial magnetic stimulation / cranial electric stimulation
- Vayarin
- Vision therapy
- Yoga
The policy states that there is insufficient evidence to support a variety of specific assessment tools, testing modalities, and treatment modalities for ADHD (the list may not be all-inclusive). These listed services and modalities are considered to lack adequate evidence for use in the assessment or treatment of ADHD per the policy and are therefore not supported.
Coding
| 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. |
| 70551 | MRI brain; without contrast material. |
| 70552 | MRI brain; with contrast material(s). |
| 70553 | MRI brain; without contrast, followed by contrast and further sequences. |
| 76390 | Magnetic resonance spectroscopy. |
| 78600 | Brain imaging, less than 4 static views. |
| 78601 | Brain imaging, less than 4 static views; with vascular flow. |
| 78605 | Brain imaging, minimum 4 static views. |
| F90.0 - F90.9 | Attention-deficit hyperactivity disorders |
ECG CPTs & billing note
Added CPT codes 93000, 93005, 93010 to the list of CPT codes considered not medically necessary when billed with a sole diagnosis of ADHD. These ECG CPTs are constrained by the policy language that ECG evaluation may be performed prior to stimulant therapy only if clinically indicated.
Provider Actions
ECG only if clinically indicated
Electrocardiogram (ECG) evaluation may be performed prior to stimulant therapy only if clinically indicated (for example, family or personal history of cardiovascular disease or congenital heart disease).
Toxicology when suspected
Perform toxicology screen prior to stimulant medication therapy if drug use is suspected.
- Perform if drug use is suspected prior to stimulant therapy.
Thyroid measurement when symptomatic
Measure thyroid hormone levels if patient exhibits clinical manifestations of hyperthyroidism.
- Measure thyroid hormone levels if clinical manifestations of hyperthyroidism are present.
Background & Evidence
Background: ADHD is one of the most commonly diagnosed neurodevelopmental disorders in children and is increasingly diagnosed in adults; core symptoms (inattention, hyperactivity, impulsivity) persist for at least six months and impair functioning. There is no single diagnostic test; diagnosis relies on a clinical assessment using DSM-5 criteria with collection of collateral information as available. Treatment modalities include pharmacotherapy (stimulants and nonstimulants) and behavioral interventions; guidelines (e.g., AAP, SDBP) provide age-specific recommendations and emphasize evaluating comorbid conditions and functional impairment. Recent updates in the policy note additions to background text that clinical trials in adults with noncomorbid ADHD suggest amphetamines as first-line treatment and state that methylphenidate is a first option for adults with moderate or severe ADHD, and that suggested first-line treatment for adults is medication rather than CBT. The policy also documents revisions clarifying that an ECG should be performed only if clinically indicated and includes additions such as pharmacogenetic tools in the list of modalities considered insufficient.
| Evidence Item | Summary |
|---|---|
| Prevalence (children/adolescents) | Estimated prevalence in U.S. children and adolescents: 9.4%. |
| Prevalence (adults) | Estimated prevalence in U.S. adults: approximately 4.4%. |
| Systematic review | Systematic review of 16 RCTs and 1 meta-analysis (2668 participants) showed benefit of extended‑release methylphenidate and amphetamines, atomoxetine, and extended‑release guanfacine in adolescents (12–18 years). |
| Cochrane review | Cochrane review (2021) evaluated immediate‑release methylphenidate for ADHD in adults (reference provided). |
| Clinical practice guideline | AAP clinical practice guideline (Wolraich et al., Pediatrics 2019) for diagnosis, evaluation, and treatment of ADHD in children and adolescents. |
Revision History
Revised language to specify ECG can be performed only if clinically indicated; added CPT codes 93000, 93005, 93010 to not medically necessary table when billed with a sole diagnosis of ADHD; added assessment of serum lipid profiles to insufficient evidence list; annual review replaced 'experimental/investigational' with 'there is insufficient evidence to support'; references reviewed, updated, reformatted; duplicate reference removed; administrative changes to headers and codes.
Updated Section I.A. to include 'collection of collateral information' and 'toxicology screen.' Updated Section I.B. to include 'ongoing assessment and application of standardized scales to assess treatment benefit.' Updated insufficient evidence lists to reflect AAP 2019 guidelines adding pharmacogenetic tools, cannabidiol oil, cognitive training, external trigeminal nerve stimulation (eTNS), mindfulness, and supportive counseling; CPT and HCPCS code updates (added G0176 and numerous EEG/CPT updates).
Annual review; updated wording and code adjustments from prior revisions (clarifications and code removals/additions); policy reviewed and references updated.
Revision noted: revised CPT descriptions for CPT-81229, 92065, 96366, 96367 and 97814; background additions stating clinical trial findings about amphetamines and methylphenidate for adults added with no change to criteria; approval by BH Clinical Policy Subcommittee (Approval Date = 02/22); administrative updates including replacing 'experimental/investigational' with 'there is insufficient evidence to support', references reformatted and duplicate removed.
References reviewed, updated, and reformatted; duplicate references removed; administrative revision of CPT descriptions and coding implications; document governance metadata added (approval noted).
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