CurrentBaylor Scott & White Health PlanPolicy 302

Digital Cognitive Behavioral Therapy

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Defines medical necessity and coverage criteria for practitioner‑prescribed digital cognitive or behavioral therapy applications (mobile software applications / prescription digital therapeutics) and lists evaluated products; applies to Baylor Scott & White Health Plan lines of business and to Medicare/Medicaid where plan-specific rules do not supersede.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDigital Cognitive Behavioral Therapy

Policy CodePolicy 302

Change TypeRevised scope, criteria, evaluated products, and coding

Effective DateMay 1, 2026

Last ReviewApr 23, 2026

Next Review DateApr 23, 2027

Key ActionObtain prior authorization and document that a licensed practitioner prescribed the MSA for a covered purpose as part of a comprehensive treatment plan.

SourceLink

POLICY UPDATE CHANGES

Revised policy scope and definitions to clarify practitioner‑prescribed digital therapeutics and explicitly exclude consumer, wellness, and provider‑operated applications; strengthened regulatory alignment language for Medicare and Texas Medicaid; updated medical necessity criteria to include FDA clearance 'when required,' added requirement for credible evidence and net health benefit, clarified provider prescription requirements, and added use as part of a comprehensive treatment plan; expanded and refined evaluated digital therapeutics table to include reSET, reSET‑O, and SleepioRx; updated codes section to add A9291 as covered, designate 98978 and T1505 as not covered, restructure code tables, and clarify that non‑covered code list is not exhaustive; updated references to reflect current evidence.

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CurrentBaylor Scott & White Health PlanPolicy 302

Digital Cognitive Behavioral Therapy

Customize your policy alerts

Sign up for Baylor Scott & White Health Plan Policy 302 alerts

Get alerted when Policy 302 changes without checking for updates manually.

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Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDigital Cognitive Behavioral Therapy

Policy CodePolicy 302

Change TypeRevised scope, criteria, evaluated products, and coding

Effective DateMay 1, 2026

Last ReviewApr 23, 2026

Next Review DateApr 23, 2027

Key ActionObtain prior authorization and document that a licensed practitioner prescribed the MSA for a covered purpose as part of a comprehensive treatment plan.

SourceLink

POLICY UPDATE CHANGES

Coverage Criteria for Prescription Digital Cognitive/Behavioral Therapy

Medical Necessity Criteria

BSWHP may consider digital cognitive behavioral therapy medically necessary when ALL of the following are met:

MSA criteria: 1) The MSA has been approved or cleared by the Food and Drug Administration (FDA) when such clearance or approval is required; 2) There is credible scientific evidence which permits reasonable conclusions regarding the impact of the MSA on health outcomes; 3) The MSA has been proven materially to improve the net health outcome or be as beneficial as any established alternative.

From Section A; all three required.

Member and provider criteria: 1) The MSA is prescribed by a licensed healthcare practitioner acting within the scope of their practice; 2) There is documentation supporting that the MSA was ordered for a covered purpose such as preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and in accordance with generally accepted standards of medical practice; 3) The requested MSA is not primarily for the convenience of the individual, caregiver, or healthcare provider; 4) The MSA is used as part of a comprehensive treatment plan, when clinically appropriate.

From Section B; all four required.

Evaluated Products

Evaluated MSAs determined medically necessary if above criteria met:

Named MSAs: Somryst for chronic insomnia (9-week prescription digital therapeutic); reSET for substance use disorder (CBT with contingency management); reSET-O for opioid use disorder (CBT with contingency management); SleepioRx for chronic insomnia (digital CBT for insomnia).

These products are considered medically necessary when medical necessity criteria are satisfied.

This policy explicitly excludes certain types of software from coverage. Applications that are available directly to consumers without a prescription (including over‑the‑counter or direct‑to‑consumer products) are not covered. Also excluded are applications intended solely for general wellness purposes and applications that are used by a healthcare practitioner within a clinical setting (including software for remote physiological monitoring or telehealth service delivery). These exclusions clarify that the policy applies only to practitioner‑prescribed digital therapeutics used to evaluate, diagnose, or treat a medical condition.

All other digital therapy applications that are not specifically listed as evaluated products in this policy are considered experimental, investigational, or unproven due to insufficient evidence from well‑designed, controlled clinical trials demonstrating efficacy. Named products (e.g., Somryst, reSET, reSET‑O, SleepioRx) are considered medically necessary only when the policy's medical necessity criteria are satisfied.

Digital CBT (prescription digital therapeutics)

Digital CBT (prescription digital therapeutics): Cognitive behavioral therapy and CBT with contingency management delivered via prescription digital therapeutics for conditions including chronic insomnia, substance use disorder, and opioid use disorder.

Products listed: Somryst, reSET, reSET-O, SleepioRx.

Billing and Coding

Covered HCPCS CodesHCPCSCovered

A9291

Prescription digital cognitive and/or behavioral therapy

Not Covered / Excluded CodesCPT | HCPCSNot Covered

98978	Remote therapeutic monitoring (e.g., therapy adherence, therapy response); device(s) supply with scheduled recordings and/or programmed alert transmission to monitor cognitive behavioral therapy, each 30 days
T1505	Electronic medication compliance management device, includes all components and accessories, not otherwise classified

Inclusive diagnosis list note

Scope of diagnosis codesPolicy notes a wide range of applicable diagnosis codes and states that an inclusive list may not be presented; specific codes may apply but are not guaranteed reimbursement.

Implication for billingInclusion of a diagnosis code in the policy’s discussion does not guarantee reimbursement; member must meet all medical necessity criteria.

Responsibility to verifyProviders should confirm current, plan‑specific applicable diagnosis codes and any recent code changes prior to submission.

Change riskBecause codes can change, the policy explicitly cautions against relying on a static inclusive list for coverage determinations.

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for digital cognitive or behavioral therapy. Coverage of A9291 (Prescription digital cognitive and/or behavioral therapy) requires meeting all medical necessity criteria in this policy and confirmation that the MSA was prescribed by a licensed healthcare practitioner within their scope of practice.

Affected code: A9291 — Prescription digital cognitive and/or behavioral therapy
Prior authorization required before services are rendered

Denial Risk

Claims and Denial Conditions

Claims may be denied if the mobile software application (MSA) does not meet the medical necessity criteria (see Section A), lacks prior authorization when required, or supporting documentation is insufficient. Ensure documentation shows the MSA was prescribed by a licensed healthcare practitioner within scope of practice; ordered for a covered purpose (preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms); used as part of a comprehensive treatment plan when clinically appropriate; and is not primarily for convenience.

Definitions

Mobile Software Application (MSA) / Digital Therapeutic

DefinitionMobile Software Applications (MSAs) / Digital Therapeutics are practitioner‑prescribed software applications used on mobile or computing devices (e.g., phone, tablet, laptop, smartwatch) intended to evaluate, diagnose, prevent, manage, or treat a medical condition.

Prescriber requirementMSAs are prescribed by licensed healthcare practitioners and intended for clinical use rather than general wellness or over‑the‑counter consumer apps.

Device/setting exclusionThis policy excludes applications integral to or used with a separate FDA‑cleared medical device, consumer direct‑to‑consumer apps, general wellness apps, and applications used only within a clinical setting for remote physiologic monitoring or telehealth delivery.

Regulatory noteDigital therapeutics intended for clinical use may undergo FDA evaluation and, when required, clearance or approval.

Background

Digital therapeutics are software‑based interventions designed to prevent, manage, or treat a specific medical condition. Unlike general wellness apps, these practitioner‑prescribed mobile software applications may require U.S. Food and Drug Administration evaluation or clearance when intended for clinical use and are intended to produce clinically meaningful health outcomes. They are prescribed by a licensed healthcare practitioner and are intended to be used as part of a comprehensive treatment plan consistent with accepted standards of medical practice.