CurrentBaylor Scott & White Health PlanPolicy 218

Attention Deficit Hyperactivity Disorder (ADHD) Testing

Defines medical necessity and coverage limits for psychological testing for Attention Deficit Hyperactivity Disorder (ADHD) for Baylor Scott & White Health Plan members; applies across lines of business and plan types with reference to plan documents and applicable Medicare/Medicaid rules.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAttention Deficit Hyperactivity Disorder (ADHD) Testing

Policy CodePolicy 218

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateApr 23, 2027

Key ActionEnsure testing is administered and interpreted by a psychologist or psychiatrist and meets medical necessity criteria before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

DSM-5-TRDiagnostic standard referenced

7 codesCovered CPT codes

3 codesNot-covered CPT codes

F90.xPrimary ICD-10 group

Coverage Criteria for Psychological Testing (ADHD)

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inv-01: Medically Necessary Criteria

Testing is considered medically necessary when ALL of the following are met (and exclusions do not apply):

Medical necessity requirements: A. The requested tests must be chosen to answer a specific question(s) that has been raised by the treating provider and are related directly to the medical, psychiatric, or psychological treatment of the patient; B. The specific question(s) cannot be answered by means of diagnostic assessment and/or behavioral observations; C. The testing results will impact the management of the member's healthcare; D. The test is administered by and interpreted by a psychologist or psychiatrist

These requirements apply only when none of the exclusion criteria are present.

Billing and Coding

Covered CPT CodesCPTCovered

96127	Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument (usually primary care)
96130	Psychological testing evaluation services by psychologist or physician (listed with 96131-96133 group)
96131	Psychological testing evaluation services (add-on as listed in policy grouping)
96132	Psychological testing evaluation services (add-on as listed in policy grouping)
96133	Psychological testing evaluation services (add-on as listed in policy grouping)
96136	Assessment administration and scoring by psychologist or neuropsychologist
96137	Assessment administration and scoring by psychologist or neuropsychologist (add-on)

Not Covered CPT CodesCPTNot Covered

96138	Psychological testing administration by technician
96139	Psychological testing administration by technician (add-on)
96146	Psychological or neuropsychological test administration, single automated instrument with automated results

Relevant ICD-10 CodesICD-10

F90.x

Attention-deficit hyperactivity disorders

Provider Requirements and Billing Implications

Prior Authorization

Prior authorization — Not applicable

Prior authorization is not applicable for ADHD testing under this policy. When testing is requested, it must meet the medical necessity criteria in the policy and must not meet any exclusion criteria.

Step Therapy

Step therapy — None specified

No step therapy rules are specified for ADHD testing under this policy.

Documentation Required

Required clinical documentation

Providers should document the clinical interview findings and include reports from parents/guardians, teachers, and other clinicians involved in the member's care. Documentation must support the specific question(s) the treating provider seeks to answer, why diagnostic assessment and/or behavioral observations alone cannot answer the question(s), how the testing results will impact management, and that testing is administered and interpreted by a psychologist or psychiatrist.

Include parent/guardian and teacher reports when available.
Record clinical interview and medical evaluation details, including history and physical exam.
Specify the clinical question(s) driving the test selection and how results will affect treatment.

Denial Risk

Exclusion-based denial triggers

Testing is excluded when performed primarily for educational or training purposes, when delivered solely via a single automated instrument with only automated results, when using EEG/event-related potentials or neuroimaging, when administered by a technician, or when related to work‑related injury or court‑ordered without documentation of medical necessity. Requests meeting any exclusion should be denied.

Excluded: services primarily educational or for academic performance (often provided by schools).
Excluded: single automated instrument/electronic platform with only automated results.
Excluded: EEG/brain mapping, event-related potentials, or neuroimaging.
Excluded: services administered by a technician.
Excluded: services for work-related injury/illness or court‑ordered without documented medical necessity.

Definitions

Psychological testing for ADHD — definition and limits

DefinitionFormal testing administered and interpreted by a psychologist or psychiatrist intended to answer a specific clinical question that cannot be resolved by diagnostic assessment or behavioral observation and that will impact patient management.

PurposeUsed when clinical interview and collateral reports (parents, teachers, other clinicians) do not provide diagnostic clarity for ADHD or differential diagnoses.

Required operator qualificationsMust be administered and interpreted by a psychologist or psychiatrist; technician-administered services (CPT 96138-96139) are excluded.

Scope limitationsDoes not include services provided primarily for educational/academic/work performance, single automated-instrument tests with only automated results (CPT 96146), EEG/event-related potentials, or neuroimaging.

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by persistent patterns of inattention and/or hyperactivity-impulsivity that impair daily functioning. Diagnosis in children and adolescents is based on DSM-5-TR clinical criteria and requires documentation of difficulties in more than one major setting (for example, at school and at home). The primary diagnostic approach is clinical interview and collateral reports (parents/guardians, teachers, and other clinicians); psychological testing has a limited, supportive role and is reserved for situations where diagnostic questions remain after standard clinical assessment.