CurrentCentenePolicy CP.BH.124

Attention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)

Defines medically necessary assessment and treatment services for ADHD and lists assessments/treatments considered insufficient evidence or not medically necessary; includes extensive coding guidance of CPT/HCPCS/ICD-10 codes considered not medically necessary when billed with a sole ADHD diagnosis.

Policy Summary

PayerCentene

PolicyAttention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)

Policy CodePolicy CP.BH.124

Change TypeCoding and criteria clarifications (ECG clinical indicationcode additions/removals)

Effective Date

Next Review Date

Key ActionDocument complete medical evaluation, DSM-5 TR–based interview information, collateral information (eg, Vanderbilt/Conners) and assessment of comorbid conditions; document lab evaluations prior to stimulant therapy when performed and rationale if ECG is obtained (must be clinically indicated).

SourceLink

POLICY UPDATE CHANGES

Clarified I.A.5.d that ECG can be performed only if clinically indicated.

Updated Section I.A. to include 'collection of collateral information' and 'toxicology screen' and I.B. to include 'ongoing assessment and application of standardized scales.'

HCPCS Code Updates: Added G0176.

Coding table updated repeatedly; specific codes added/removed across 2020–2025 revisions.

Policy statement III added to clarify educational interventions exclusion.

Several items removed or added (supportive counseling removed; Vayarin removed).

Clarification of clinical indication requirement.

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1Primary policy statement (assessment + treatment)

40+CPT/HCPCS codes listed as not medically necessary

1ICD-10 code range listed as unsupported when sole diagnosis

MultipleCPT/HCPCS codes listed/updated

ManyInterventions listed as insufficient evidence/not medically necessary

CP.BH.124Policy reference number

Coverage Summary

Scope: Defines medically necessary assessment and treatment services for ADHD and enumerates assessments and treatments considered insufficient evidence or not medically necessary; includes extensive coding guidance listing CPT/HCPCS/ICD-10 codes that are not medically necessary when billed with a sole ADHD diagnosis.

Subject & status: Attention Deficit Hyperactivity Disorder assessment and treatment; policy number CP.BH.124; status CURRENT.

Primary policy statement (synopsis): Services are medically necessary for ADHD when they include appropriate assessment (DSM-5 TR–based interview, collateral information, medical evaluation, and indicated laboratory/cardiac screening) and treatment (pharmacotherapy, behavioral modification, treatment of comorbid conditions, and ongoing standardized assessment); the policy also lists numerous assessments, treatments, and specific procedure codes that are considered not medically necessary or have insufficient evidence and provides coding/billing constraints when ADHD (F90.x) is the sole diagnosis.

Key thresholds and metadata

Duration of symptoms for ADHD diagnosiscontinued for at least six months

Last review03/25

Next review

Policy reference numberCP.BH.124

Primary policy statement count1

Medically Necessary: Assessment and Treatment Criteria

Medically Necessary Services for ADHD Assessment and Treatment

Covered when ALL of the following are met:

ALL of the following

- Assessment components
  - Complete medical evaluation with history and physical examination.
  - Parent/child interview or patient interview, if adult, to obtain information listed in Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5 TR).
  - Collection of collateral information, if available, such as the Vanderbilt or Conners assessment.

Assessments Considered Insufficient Evidence / Not Medically Necessary

Educational Interventions

Interventions strictly educational in nature are not medically necessary:

ALL of the following

Educational Interventions
- Classroom environmental manipulation, academic skills training, and other strictly educational interventions are not medically necessary as they are not medical interventions

Coding (Not Medically Necessary / Policy Coding Guidance)

Specific CPT, HCPCS, and other procedure codes are listed as not medically necessary when billed with a sole diagnosis code of ADHD. The coding tables reflect multiple revision updates to this policy; providers must ensure that codes billed for ADHD-related services are supported by appropriate clinical documentation and bycomitant diagnosis codes when required.

Provider Actions / Billing Rules

Documentation Required

Assessment documentation

Document a complete medical evaluation including history and physical examination; a DSM-5 TR–based interview (parent/child or patient interview for adults); collection of collateral information when available (e.g., Vanderbilt or Conners assessments); assessment of comorbid behavioral health and medical diagnoses; laboratory evaluations prior to stimulant medication therapy when performed (examples: CBC, LFTs, toxicology if indicated); and if an ECG is obtained document the clinical rationale (ECG should be obtained only if clinically indicated).

Complete medical evaluation with history and physical examination
Parent/child interview or patient interview to obtain DSM-5 TR information
Collection of collateral information (e.g., Vanderbilt or Conners assessment)
Assessment of comorbid behavioral health and/or medical diagnoses
Laboratory evaluation prior to stimulant therapy (e.g., CBC, liver function tests, toxicology if indicated)
Document rationale if ECG is obtained (ECG only if clinically indicated)

Documentation Required

Background and Evidence

Background: The policy aligns assessment and treatment approaches with the DSM-5 TR diagnostic framework and professional guidelines (American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics), notes that ADHD is a common neurodevelopmental disorder with increasing recognition in adults, and emphasizes that no single test establishes diagnosis — clinical assessment is required.

Support for interventions: Consistent with guideline guidance, the policy supports age-based recommendations including behavioral parent training and classroom interventions for younger children and pharmacotherapy (stimulants and selected nonstimulants) plus behavioral interventions for school-aged children, adolescents, and adults as appropriate; it also references SDBP guidance for complex ADHD and endorses pharmacotherapy and behavioral interventions per those age-based recommendations.

Guideline	Use in Policy
AAP Clinical Practice Guideline (2019)	Informed age-based recommendations for evaluation and treatment (behavioral interventions first in preschool; combined pharmacologic and behavioral approaches for school-aged and adolescents), supported inclusion of collection of collateral information and ongoing standardized scales; cited in Background and used to define assessment and treatment components in Policy I.A and I.B.
SDBP Clinical Practice Guideline	Provided companion guidance for assessment and treatment of complex ADHD emphasizing functional impairment, psychosocial treatment as foundational, interprofessional care, and use of diagnostic assessment/testing appropriately; cited in Background and incorporated into policy discussions on complex ADHD care and treatment algorithms.

ECG and Cardiac/Serum Testing Billing Context

ECG and lab billing context: The policy clarifies that ECG (CPT 93000, 93005, 93010) may be performed only if clinically indicated (for example, personal or family history of cardiovascular disease or congenital heart disease) and that those ECG CPT codes were added to the not medically necessary table when billed with a sole ADHD diagnosis.

The policy also states specific serum/lab codes (including lipid and thyroid-related codes such as 80061, 83718, 83719, 82721, 83722, 84475) were added to the not medically necessary table when billed with a sole ADHD diagnosis; these changes are recorded in the revision log clarifying the clinical indication requirement and the corresponding coding table updates.

Revision History

05/21revised

Replaced 'experimental/investigational' verbiage with 'there is insufficient evidence to support' across policy language; references reviewed and reformatted.

02/22revised

Replaced 'experimental/investigational' verbiage with 'there is insufficient evidence to support' (noted again in annual review); background updated with adult ADHD treatment findings (no impact to clinical criteria).

clarified

Policy Summary

PayerCentene

PolicyAttention Deficit Hyperactivity Disorder Assessment and Treatment (PDF)

Policy CodePolicy CP.BH.124

Change TypeCoding and criteria clarifications (ECG clinical indicationcode additions/removals)

Effective Date

Next Review Date

SourceLink

On This Page

Complete psychiatric evaluation or other services provided by a psychiatrist, psychologist, or other behavioral health professional.

Measurement of thyroid hormone levels if patient exhibits clinical manifestations of hyperthyroidism.

Assessment of comorbid behavioral health and/or medical diagnoses and associated symptoms.

When not otherwise excluded, other services for the assessment of ADHD to meet the DSM-5 TR criteria.

Laboratory evaluation prior to stimulant medication therapy
- Complete blood count.
- Liver function tests.
- Toxicology screen if drug use is suspected.
- Cardiac evaluation and screening. Electrocardiogram (ECG), if clinically indicated (e.g., family or personal history of cardiovascular disease or those with congenital heart disease).

Treatment modalities
- Pharmacotherapy.
- Behavioral modification.
- Treatment of comorbid behavioral health and/or medical diagnoses and associated symptoms.
- When not otherwise excluded, other services for the treatment of ADHD.
- Ongoing assessment and application of standardized scales to assess treatment benefit.

Coding and Billing Constraints (Not Medically Necessary when billed with sole diagnosis of ADHD)

Services billed with only a diagnosis code for ADHD may be reviewed for medical necessity; some assessment services or procedures are considered not medically necessary when submitted with a sole diagnosis of ADHD without supporting documentation of symptoms, comorbidities, or clinical indications meeting DSM-5 TR criteria.
Assessment or treatment procedures listed as 'insufficient evidence' or 'not medically necessary' in policy (e.g., computerized EEG/qEEG/NEBA, neuroimaging, pharmacogenetic testing, actigraphy, various alternative therapies) are not covered even if billed with an ADHD diagnosis unless medical necessity is clearly documented and aligns with policy exceptions.
Providers must submit supporting clinical documentation (history, examination findings, DSM-5 TR criteria, standardized rating scale results, prior treatment attempts where applicable) when billing for assessment or treatment services for ADHD to avoid claim denials.

Clinical indication required for ECG

ECG CPTs 93000, 93005, and 93010 may be performed only if clinically indicated (for example, personal or family history of cardiovascular disease or congenital heart disease). These ECG codes were added to the not medically necessary list when billed with a sole ADHD diagnosis and may be considered not medically necessary if submitted with only an F90.x diagnosis without additional clinical justification.

93000
93005
93010
Note: ECG may be considered not medically necessary if billed with sole ADHD diagnosis (F90.x) without clinical indication or additional justification.

Billing Rule

Coding restrictions for sole ADHD diagnosis

Do not bill the enumerated CPT/HCPCS/lab codes as medically necessary when submitted with a sole diagnosis of F90.x (ADHD). Ensure additional diagnoses or clinical justification are present on the claim; otherwise claims for these codes may be denied as not medically necessary. Lab codes (e.g., lipid panel and related codes) have also been added to the not medically necessary list when billed with a sole ADHD diagnosis.

Do not bill listed CPT/HCPCS codes as medically necessary when submitted with only F90.0–F90.9 (ADHD)
Ensure additional diagnoses or clear clinical justification are present if billing these procedures
Claims may be denied if codes are billed with sole ADHD diagnosis
Lab codes (e.g., 80061, 83718, 83719, 82721, 83722, 84475 and others) were added to the not medically necessary list when billed with sole ADHD diagnosis

Clarified I.A.5.d that ECG can be performed only if clinically indicated (e.g., family or personal history of cardiovascular disease or congenital heart disease).

coding_update

Added CPT codes 93000, 93005, and 93010 to the not medically necessary table when billed with a sole ADHD diagnosis; ECG codes may be allowed only if clinically indicated.

added

Added assessment of serum lipid profiles to insufficient-evidence/ not medically necessary assessment list and added lab CPT codes (80061, 83718, 83719, 82721, 83722, 84475) to not medically necessary table when billed with sole ADHD diagnosis.

revised

Updated Section I.A. to include 'collection of collateral information' and 'toxicology screen' and updated Section I.B. to include 'ongoing assessment and application of standardized scales.'

added

HCPCS update: Added G0176 to the HCPCS not medically necessary table when billed with a sole ADHD diagnosis.

coding_update

Multiple CPT/HCPCS code updates across revisions (added many EEG/EMG and other codes such as 78803, 81171, 81172, 92547, 95705-95726, 96121, 97129, 97130; removed codes including 78607, 95827, 97127 and later removed deleted CPTs like 92569).

added

Policy statement III added clarifying that interventions strictly educational in nature (e.g., classroom environmental manipulation, academic skills training) are not medically necessary.

03/24revised

Removed 'Supportive counseling' and 'Vayarin' from II.B; replaced 'EndeavorRx' with 'Video game-based interventions (e.g., EndeavorRx, AKL-T01)'; added CPT codes 70544–70546, 95957 and CPT 97151–97158 for ABA services to not medically necessary table.

03/25revisedLatest

Periodic code maintenance: removed CPT codes 84437, 96116, 96121 from not medically necessary table and added CPT codes 92066, 92545, 92546, 92548, and 96369; added 'which, when billed as the only diagnosis code(s)...' wording to ICD-10 table; removed duplicate criteria and updated coding lists.