CurrentArizona Complete HealthPolicy CP.MP.124

Clinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment

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.

Policy Summary

PayerArizona Complete Health

PolicyClinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment

Policy CodePolicy CP.MP.124

Change TypeAnnual review; multiple revisions (revised, added, clarified)

Effective Date

Next Review Date

Key ActionPerform ECG only if clinically indicated prior to stimulant therapy; perform toxicology screen if drug use is suspected; measure thyroid hormone levels if symptomatic.

SourceLink

POLICY UPDATE CHANGES

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.

40+

CPT/HCPCS codes listed not medically necessary

2Assessment and Treatment categories marked medically necessary

60+Assessment/Treatment modalities considered insufficient

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.

Key evidence and guideline highlights

Prevalence (children/adolescents, US)9.4%

Prevalence (adults, US)~4.4%

Clinical practice guidelineWolraich et al., Pediatrics 2019

Systematic review summary16 RCTs and 1 meta-analysis (2668 participants) demonstrated benefit of extended-release methylphenidate and amphetamines, atomoxetine, ER guanfacine in adolescents

Cochrane review (2021)Immediate-release methylphenidate for adults (ref 17)

Medically-Necessary Criteria

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

Coding

CPT codes considered not medically necessary when billed with a sole diagnosis of ADHDCPTNot 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.
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.

1–10 of 110

1/11

HCPCS codes considered not medically necessary when billed with a sole diagnosis of ADHDHCPCSNot Covered

G0176	Activity therapy, such as music, dance, art or play therapies related to disabling mental health problems, per session (45 minutes or more).
P2031	Hair analysis (excluding arsenic).
S8040	Topographic brain mapping.

ICD-10 codes referencedICD-10

F90.0 - F90.9

Attention-deficit hyperactivity disorders

Revised CPT descriptions mentionedCPT

81229	CPT-81229 (description revised in policy)
92065	CPT-92065 (description revised in policy)
96366	CPT-96366 (description revised in policy)
96367	CPT-96367 (description revised in policy)
97814	CPT-97814 (description revised in policy)

Billing Rule

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.

93000
93005
93010
Not medically necessary when billed with a sole ADHD diagnosis; ECG only if clinically indicated.

Provider Actions

Documentation Required

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).

93000
93005
93010
Example indications: family or personal history of cardiovascular disease; congenital heart disease

Documentation Required

Toxicology when suspected

Perform toxicology screen prior to stimulant medication therapy if drug use is suspected.

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

04/21revised

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.

05/20revised

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).

Policy Summary

PayerArizona Complete Health

PolicyClinical Policy: Attention Deficit Hyperactivity Disorder Assessment and Treatment

Policy CodePolicy CP.MP.124

Change TypeAnnual review; multiple revisions (revised, added, clarified)

Effective Date

Next Review Date

Key ActionPerform ECG only if clinically indicated prior to stimulant therapy; perform toxicology screen if drug use is suspected; measure thyroid hormone levels if symptomatic.

SourceLink

On This Page

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

Measurement of peripheral brain-derived neurotrophic factor

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.

Perform if drug use is suspected prior to stimulant therapy.

Documentation Required

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.

05/21annual_review

Annual review; updated wording and code adjustments from prior revisions (clarifications and code removals/additions); policy reviewed and references updated.

02/22revisedLatest

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.

ongoing/annualadministrativeLatest

References reviewed, updated, and reformatted; duplicate references removed; administrative revision of CPT descriptions and coding implications; document governance metadata added (approval noted).