CPT 90868 is referenced in 31 tracked payer policy changes from Anthem BCBS, Excellus BlueCross BlueShield, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 90868 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
HealthKeepers' Virginia Medicaid notice (dated October 15, 2026) lists which psychiatric residential treatment facility (PRTF) services are paid through fee-for-service Medicaid instead of the managed care plan, and which stay with the plan. The notice header says it is effective November 1, 2026, which has already passed, while its text describes the carve-out as effective November 1, 2025, so confirm the current routing.
The transcranial magnetic stimulation and cranial electrotherapy stimulation policy (3.01.09) has a current effective date of January 23, 2026, after a 09/17/26 edit corrected the date from January 22, 2026 to align with the New York State approval notification date. The 01/22/26 annual review allowed treatment of obsessive-compulsive disorder, lowered the minimum age for treatment of major depressive disorder to 15 years old, and added codes and investigational statements for functional connectivity MRI-guided stimulation, precuneus magnetic stimulation and cranial electrotherapy stimulation. Under the policy, an initial course of TMS is medically appropriate for severe major depressive disorder in members 15 or older after documented failure of an adequate psychotherapy trial and medication trials, and for obsessive-compulsive disorder in members 18 or older after documented resistance to an adequate psychotherapy trial and two or more medication trials.
Community Health Plan of Imperial Valley is updating prior authorization requirements effective December 1, 2025, removing PA requirements for many services including genetic testing, oxygen supplies, and various surgical procedures, while maintaining or adding PA requirements for specific services like TMS therapy and certain hernia repairs.
Health Net California is updating prior authorization requirements effective December 1, 2025, removing PA requirements for some services while adding requirements for others. Key changes include removing PA requirements for ABA therapy, physical therapy, and genetic testing while maintaining PA requirements for TMS, certain surgeries, and specific pharmaceuticals.
Aetna's updated EMDR therapy policy (CPB 0583, effective 2025-09-09) narrows coverage to PTSD treatment only. All other EMDR indications—including anxiety disorders, chronic pain, mood disorders, autism, eating disorders, and 40+ other conditions—are now classified as experimental/investigational and not covered. Billing teams must immediately deny or route claims for non-PTSD EMDR to medical review, and update system edits to flag these as non-covered services.
Aetna has updated its EMDR therapy policy (CPB 0583) to cover EMDR ONLY for post-traumatic stress disorder (PTSD) treatment. All other uses—including anxiety disorders, chronic pain, depression, autism, substance abuse, and 40+ other conditions—are now classified as experimental/investigational and NOT covered. Billing teams must immediately deny or reject claims for EMDR when diagnoses fall outside the narrow PTSD coverage scope.
Transcranial magnetic stimulation (TMS) using an FDA-cleared device and modality, which can include conventional TMS, deep TMS and theta burst stimulation, may be considered medically necessary as treatment of major depressive disorder when the listed criteria are met. TMS for major depressive disorder that does not meet the criteria is considered investigational, and continued TMS as maintenance therapy is considered investigational. The 09/15/2026 update added CPT codes 0889T, 0890T, 0891T and 0892T to the Covered Codes table for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation and updated the policy guidelines regarding treatment. TMS for all other psychiatric and neurologic disorders, including bipolar disorder, schizophrenia, obsessive-compulsive disorder or migraine headaches, is considered investigational.
Independence Blue Cross updated Medicare Advantage policy MA07.035h effective 10/19/2026 to clarify TMS treatment duration, tapering schedules, and coverage criteria. Key changes: multiple daily TMS sessions are now covered only under the SAINT protocol; SAINT/iTBS criteria were updated to define covered treatment days and target development requirements; and target development services (CPT 0889T) are now explicitly included in initial SAINT treatment costs.
Independence Blue Cross updated its Therapeutic Transcranial Magnetic Stimulation (TMS) policy effective 10/19/2026 to clarify that standard TMS treatment duration, tapering schedules, and multiple daily TMS sessions are covered only under the Stanford Accelerated Intelligent Neuromodulation Therapy (SAINT) protocol. The policy also refined SAINT/iTBS criteria for covered treatment days and target development requirements, and clarified that target development services are included in initial SAINT treatment.
Blue Shield of California updated its medical policy BSC2.19 for transcranial magnetic stimulation (TMS), effective May 1, 2026. TMS using an FDA-cleared device and modality may be considered medically necessary when the patient has a diagnosis of Major Depressive Disorder (single or recurrent), is age 15 or above, and meets one or more of these: treatment resistant depression supported by an inadequate response to 2 antidepressant medications at a therapeutic dose and adequate duration, or to 1 antidepressant medication plus 1 adjunctive medication at a therapeutic dose and adequate duration; tolerability concerns with medication options; or a history of a positive response to TMS in a previous depressive episode. Continued treatment with TMS as maintenance therapy is considered investigational.
Independence Blue Cross updated MA07.035g to add two new CPT codes (0997T, 0998T) for Transcranial Magnetic Stimulation (TMS) treatment effective January 1, 2026. The policy reinforces coverage criteria for TMS in Medicare Advantage members aged 15+ with severe major depressive disorder who have failed medication trials or demonstrate intolerance to psychopharmacologic medications. Billing teams must recognize and apply the new codes when TMS services meet all documented medical necessity criteria.
Independence Blue Cross updated TMS policy 07.03.22h effective 01/01/2026 to add two new CPT codes (0997T, 0998T) for personalized target development and accelerated theta-burst stimulation. The policy clarifies specific behavioral health criteria for TMS coverage in treatment-resistant major depressive disorder, requiring documentation of medication resistance, intolerance, or prior TMS response using standardized rating scales.
Independence Blue Cross updated MA07.035f to MA07.035g, expanding TMS coverage to include adolescents ages 15 and older (previously adult-only) and adding NeuroStar Advanced Therapy as an FDA-approved adjunct for adolescent MDD. The policy now includes specific examples of required medication trial drug classes (SSRIs, SNRIs, TCAs, MAOIs, and others) and standardized rating scales for measuring depressive symptoms. Documentation requirements and clinical criteria remain largely unchanged.
Independence Blue Cross updated TMS policy 07.03.22g to 07.03.22h, expanding coverage to adolescents ages 15 and older (previously adult-only) following FDA approval of NeuroStar Advanced Therapy for this population. The policy now includes specific medication class examples, updated literature for OCD and adolescent MDD, and revised policy numbering to MA07.035f. Coverage criteria and clinical requirements remain substantially the same but now explicitly include adolescent treatment pathways.
CalViva Health is streamlining prior authorization requirements effective December 1, 2025, removing PA requirements for several services including oxygen, genetic testing, and certain surgeries while maintaining PA for others like TMS and specific cardiovascular procedures. This affects Medi-Cal providers in Fresno, Kings, and Madera counties in California.
Effective October 1, 2025, Blue Shield of California considers repetitive transcranial magnetic stimulation (rTMS) medically necessary for depression when all of the following are met: an FDA-cleared device and modality are used, the patient is an adult aged 18 or older with moderately-severe to severe major depressive disorder without psychosis documented by standardized rating scales, and the chart documents one or more of these: an inadequate response to two antidepressants from two different classes at a therapeutic dose and adequate duration, an inadequate response to one antidepressant plus one adjunctive medication, an inability to tolerate at least two antidepressants from two different classes due to side effects, or a positive response to rTMS in a previous depressive episode. An adequate failed trial of psychotherapy is also required unless a prior positive response to rTMS is documented. Continued rTMS as maintenance therapy is investigational, and rTMS is investigational for all other psychiatric and neurologic disorders.
Aetna's Clinical Policy Bulletin 0625 on dysphagia therapy states which treatments it considers medically necessary and which it considers experimental, investigational, or unproven. Speech therapy for dysphagia, esophageal dilation for symptomatic obstruction of the esophagus, and non-biodegradable, non-drug eluting stent placement for refractory malignant esophageal strictures are medically necessary when the member meets the policy's criteria. Acupuncture, electrical stimulation, transcranial direct current stimulation, hyperbaric oxygen therapy for radiation-induced dysphagia and several other interventions are listed as experimental, investigational, or unproven.
Aetna considers constraint-induced movement therapy (CIMT) medically necessary for upper limb hemiparesis in persons with stroke who have at least 10 degrees of active wrist and finger extension and no sensory or cognitive deficits, and for upper limb hemiparesis in hemiplegic cerebral palsy. Coverage is for a 4-week CIMT program that can be extended by another 4 weeks when documentation shows improvement of functions. CIMT for lower limb hemiparesis, brachial plexus palsy, multiple sclerosis, Parkinson's disease, spinal cord injury, traumatic brain injury and hemiplegia from brain tumors, along with several CIMT combinations and related therapies, are considered experimental, investigational or unproven.
Aetna considers physical therapy, perineoplasty, and vestibulectomy (local or total) medically necessary for vulvodynia and vulvar vestibulitis. Vestibulectomy is considered medically necessary for persons who have failed conservative measures (including vulvar care, physical therapy, and pharmacotherapy including analgesics) and who have had a musculoskeletal evaluation that ruled out factors such as pelvic muscle over-activity and myofascial or other biomechanical disorders, or a 3-month trial and failure of treatments for those disorders. Acupuncture, botulinum toxin, laser therapy, sacral neuromodulation, spinal cord stimulation, TENS, hypnotherapy, and many other listed treatments are considered experimental, investigational, or unproven for this indication because their effectiveness has not been established.
Aetna considers TMS medically necessary for members age 15 or older with severe major depressive disorder without psychosis when the treatment uses an FDA-cleared device for its labeled indications and a psychiatrist has confirmed the diagnosis with a standardized rating scale. Coverage also requires documented inadequate response to two antidepressant trials of at least 8 weeks each, plus augmentation therapy for adults or psychotherapy or augmentation for adolescents, and treatment is limited to a maximum of 30 sessions over 6 weeks plus 6 tapering sessions, with treatment beyond 36 sessions reviewed for medical necessity. Accelerated TMS, MRI-guided TMS, MeRT, adjunctive ketamine with TMS, maintenance TMS and TMS for most other listed conditions are considered experimental, investigational or unproven, as is cranial electrical stimulation for the indications named in the policy.
Aetna considers cognitive behavioral therapy medically necessary for tinnitus when the tinnitus persists for 6 months or more, treatable causes such as cerumen impaction, ear infection, vascular pathology, ototoxic medications, Meniere's disease and acoustic neuroma have been ruled out, the tinnitus causes clinically significant distress or functional impairment, and a licensed mental health professional trained in CBT delivers the therapy. Cortical mastoidectomy with restoration of separation between the sigmoid sinus and middle ear is also considered medically necessary for tinnitus from a bony defect when a sigmoid sinus dehiscence is documented on temporal bone imaging. Tinnitus instruments such as maskers and hearing aids are considered experimental, investigational, or unproven, along with a list of other tinnitus interventions that includes acupuncture, cochlear implants, TENS, transcranial magnetic stimulation and vagus nerve stimulation.
Aetna considers melodic intonation therapy medically necessary for Broca's (expressive, non-fluent) aphasia when all five selection criteria are met: good auditory comprehension; a well-motivated, emotionally stable member with a good auditory span; poor repetition, even for single words; no evidence of bilateral brain involvement; and non-fluent verbal production with diminished articulator agility and effortful initiation of speech. The policy lists melodic intonation therapy as experimental, investigational or unproven for dysarthria, other types of aphasia, verbal apraxia, neurogenic communication impairments secondary to Parkinson's disease and dementia, and raising trans women's singing and speaking fundamental frequencies, and it lists adjunctive transcranial magnetic stimulation or transcranial brain stimulation with melodic intonation therapy for aphasia as experimental too.
Aetna considers visual training and behavioral vision therapy for members with dyslexia or learning disabilities, ChromaGen lenses for improving learning skills in children with dyslexia, colored filtered or tinted lenses for dyslexia or learning disabilities, MoveR training, music-based interventions for individuals with learning disabilities, non-invasive brain stimulation including transcranial direct current stimulation for dyslexia, and pulsed lighting for dyslexia experimental, investigational or unproven because their effectiveness has not been established. There is no known eye or visual cause for dyslexia and learning disabilities and no effective visual treatment, and multidisciplinary evaluation and management must be based on proven procedures demonstrated by valid research. CPT codes 90867, 90868, 90869 and 92065, HCPCS codes A4541, E0733 and G0176, and the listed ICD-10 codes are not covered for the indications listed in the policy.
Aetna's Clinical Policy Bulletin 0852 on neurogenic bladder, last reviewed 12/23/2025, considers enterocystoplasty (augmentation cystoplasty) or urinary diversion surgery medically necessary when conservative treatments, including anticholinergic medications and urinary catheters, have failed or are contraindicated. The policy considers a long list of other treatments experimental, investigational or unproven for neurogenic bladder, including acupuncture, beta-agonists such as mirabegron, biofeedback, peripheral neuromodulation (pudendal, sacral and tibial nerve stimulation), TENS, transcranial magnetic stimulation, transurethral electrical stimulation, and intravesical gentamicin or neomycin-polymyxin. CPT codes 51960 (enterocystoplasty) and 50825 (continent diversion) are covered if selection criteria are met.
Aetna considers constraint-induced movement therapy (CIMT) medically necessary for upper limb hemiparesis in persons with stroke who have at least 10 degrees of active wrist and finger extension and no sensory and cognitive deficits, and for upper limb hemiparesis in hemiplegic cerebral palsy. Coverage is for a 4-week CIMT program that can be extended for another 4 weeks if there is documentation of improvement of functions. CIMT for brachial plexus palsy, hemiplegia from brain tumors, lower limb hemiparesis in stroke, multiple sclerosis, Parkinson's disease, spinal cord injury and traumatic brain injury, and CIMT combined with peripheral nerve stimulation, transcranial stimulation, biofeedback or electroacupuncture, are considered experimental, investigational or unproven.
Aetna Clinical Policy Bulletin 0625 addresses dysphagia therapy and sets the criteria for speech therapy, esophageal dilation and stent placement. Speech therapy for dysphagia is considered medically necessary, regardless of the presence of a communication disability, when the member has weight loss or malnutrition from dysphagia and cannot obtain adequate nutrition orally, has a history of or high risk for recurrent aspirations or choking, or is unable to swallow and has a nasogastric or gastrotomy tube for nutrition. Esophageal dilation for symptomatic obstruction of the esophagus and non-biodegradable, non-drug eluting stent placement for refractory malignant esophageal strictures are also considered medically necessary, while many other treatments such as acupuncture, electrical stimulation, mirror therapy and transcranial stimulation are considered experimental, investigational or unproven because their effectiveness has not been established.
Aetna considers electroconvulsive therapy medically necessary for members with bipolar disorder, catatonia, certain acute schizophrenic or schizoaffective disorder exacerbations, major depressive disorder, mania, severe or refractory neuroleptic malignant syndrome, or treatment-resistant schizophrenia as an adjunct to antipsychotic therapy, when the member is at least 12 years old and meets one of six listed selection criteria. Multiple monitored ECT, ultrabrief bilateral ECT and adjunctive ketamine in ECT are considered experimental, investigational or unproven, as is ECT for a long list of other indications such as dysthymic disorder, dementia-associated agitation, post-traumatic stress disorder and obsessive-compulsive disorder. CPT 00104 and 90870 are covered when the selection criteria are met, 90870 is not covered for ultrabrief bilateral ECT, and several transcranial magnetic stimulation, functional MRI, HCPCS E0732 and HCPCS J0654 codes are not covered for the indications listed in the policy.
Aetna considers these services medically necessary for members with anorexia nervosa or bulimia nervosa: medical evaluation with history and physical examination, psychiatric or psychological consultation and testing, blood count and serum chemistry, albumin and prealbumin, liver function tests, electrocardiography, urinalysis, thyroid function testing (TSH), bone density measurement for evaluation of anorexic members, and LH, FSH and estradiol for women with amenorrhea or oligomenorrhea. Treatment considered medically necessary includes nutritional counseling, psychotherapy (such as cognitive behavioral therapy, dialectical behavior therapy, family-based, interpersonal and psychodynamic psychotherapy), and enteral nutrition as a last resort for the treatment of anorexia nervosa. Self-administered pharmacotherapies are managed under the pharmacy benefit. The policy lists CPT and HCPCS codes covered if selection criteria are met, and codes not covered for the indications listed. Aetna considers a long list of services experimental, investigational or unproven for anorexia nervosa, bulimia nervosa and binge-eating disorder, including brain imaging, EEG, routine screening of asymptomatic adolescents and adults for eating disorders, acupuncture, deep brain stimulation, electroconvulsive therapy, repetitive transcranial magnetic stimulation, cannabinoids, oxytocin and ghrelin agonists.
The policy for sensory stimulation for coma patients remains unchanged - all sensory stimulation treatments continue to be classified as investigational and are not covered. The most recent update only refreshed source citations without changing coverage status.
Wellcare's Diamond Designation Program rates specialist groups for Program Year 2025 on quality and efficiency, based largely on health plan claims from January 2021 through December 2023. The program covers 14 specialty types, including cardiology, orthopedic surgery, podiatry, psychiatry and pulmonology, and quality is emphasized over efficiency. Ratings are made available to primary care practitioners who refer members to specialty care, and the program is not used to determine payment under Wellcare pay-for-performance programs.
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