CPT 97129, in plain terms, covers Therapeutic intervention aimed at cognitive function such as attention, memory, problem solving and executive skills, with direct patient contact, covering the first 15 minutes. CPT 97129 is referenced in 19 tracked payer policy changes from Sentara Health Plans, Harvard Pilgrim Health Care, and 8 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 97129 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 97129 on AAPC
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Point32Health will continue telehealth coverage for Medicare Advantage members as supplemental benefits effective October 1, 2025, regardless of CMS decisions. Specific codes across multiple specialties including cardiac rehab, mental health, physical therapy, and pulmonary rehab will remain eligible for telehealth reimbursement.
Cognitive rehabilitation may be considered medically necessary only for individuals with cognitive impairment and related functional impairment due to moderate to severe traumatic brain injury, and only when all of the listed criteria are met. Cognitive rehabilitation is considered investigational for mild traumatic brain injury, mild cognitive impairment, Alzheimer's disease, stroke, multiple sclerosis, post-acute sequelae of SARS-CoV-2 infection, epilepsy, and cognitive deficits from childhood cancers, adult brain tumors, or non-central nervous system tumors, and it is not eligible for coverage. The earlier statement applied to cognitive impairment due to traumatic brain injury without the moderate to severe limit. The policy revision is dated 05/15/2026.
Health First Colorado claims are paid only when the billing, attending, rendering and referring provider IDs are actively enrolled and revalidated, and denied claims are to be corrected and resubmitted electronically as new claims. Claims requiring an OPR or attending provider begin denying effective July 1, 2024 when that provider is missing or not enrolled, and nursing facility claims with a missing or not enrolled attending provider are denied under the same EOB 1997 rule. Fee-for-service rates increase 2.0% for dates of service starting July 1, 2024, with targeted rate increases for listed services, and claims billed and paid at a lower rate cannot be adjusted up under the lower-of pricing logic.
The HCPCS code lists used for skilled nursing facility consolidated billing are updated effective October 1, 2026, with implementation on October 5, 2026. Codes added to the Part A and Part B lists include 1027T, C1609, 1050T, 1051T, 90616, 90639 and 1036T, and certain therapy codes are removed from Part B SNF CB File #1 and remain on File #4. The update also corrects therapy codes that had been included in both Part B SNF CB File #1 and File #4.
CMS's October 2026 quarterly update revises the lists of HCPCS codes subject to skilled nursing facility (SNF) consolidated billing (CB), with an effective date of October 1, 2026 and an implementation date of October 5, 2026. Therapy codes that were inadvertently in both Part B SNF CB File #1 and File #4 are removed from File #1 and remain assigned to File #4. Other codes are added to or terminated from the Part A and Part B SNF CB files, with some of those changes effective on earlier dates.
Kansas HCBS Brain Injury Waiver cognitive therapy services must now be billed exclusively using CPT code 97129 instead of previously used codes 97535 and 97537. The new code has a rate of $25.00 per 15-minute unit and special billing rules for BI Waiver members.
Nevada Medicaid has fixed a system error that was incorrectly denying claims for cognitive therapy and sensory integration procedures (CPT codes 97129, 97130, and 97533) from physical and occupational therapy providers. Claims with dates of service from January 1, 2026 that were previously denied will be automatically reprocessed for payment.
Kansas HCBS Brain Injury Waiver will revert from using CPT codes 97535/97537 to 97129/97130 for Cognitive Therapy services effective February 1, 2026. Providers can retroactively resubmit denied claims from February 2024-2026 using modifier 59 for same-day cognitive and other therapy services.
Nevada Medicaid is removing prior authorization requirements for certain speech therapy services effective January 1, 2026, but only for patients under age 26 with specific stutter diagnoses. Prior authorization will still be required for patients age 26 and older or without qualifying stutter diagnoses.
Nevada Medicaid has removed prior authorization requirements for specific speech therapy services for patients under age 26 diagnosed with stuttering disorders, effective January 1, 2026. This applies to 12 specific CPT codes when treating patients with designated fluency disorder diagnoses.
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 cognitive rehabilitation medically necessary as adjunctive treatment of cognitive deficits when it is performed by a licensed health care professional within their scope of practice and all of the following are met: neuropsychological testing has been performed and its results will be used in treatment planning and directing rehabilitation strategies; the cognitive deficits were acquired from moderate to severe traumatic brain injury, brain surgery, stroke, or encephalopathy; a psychiatric evaluation by a licensed mental health provider has been received when there is a behavioral health concern or possible comorbid condition; the member can actively participate in a program (not comatose or in a vegetative state); and the member is expected to make significant cognitive improvement. Cognitive rehabilitation is considered experimental, investigational or unproven for indications including mild traumatic brain injury (including sports-related concussion), dementia, long COVID, multiple sclerosis, ADHD, autism spectrum disorders, coma stimulation, and virtual reality therapy for acquired cognitive disorders. Outpatient cognitive rehabilitation coverage is subject to applicable benefit plan terms and limitations for physical and occupational therapy.
Aetna's Clinical Policy Bulletin 0796 considers near-infrared (NIR) spectroscopy experimental, investigational or unproven for a long list of indications, including monitoring cerebral perfusion during cardiac and non-cardiac surgery, use in the intensive care and neonatal intensive care settings, evaluating dementia, diagnosing mood disorders and schizophrenia, assessing pain, and treatment of restless legs syndrome. The policy also considers NIR intravascular ultrasound coronary imaging (for example the InfraReDx LipiScan IVUS Imaging System) experimental for all indications. It considers NIR spectroscopy using spatial frequency domain imaging (for example the Ox-Imager CS device) unproven for identifying and evaluating vascular tissue compromise and for all other indications, because there is a lack of clinical studies demonstrating that this approach improves clinical outcomes. Non-contact NIR spectroscopy (for example SnapshotNIR) is considered unproven for intra-operative wound assessment and all other indications because of insufficient evidence of its effectiveness.
Aetna's Clinical Policy Bulletin 0325 sets the medical necessity rules for physical therapy. PT is considered medically necessary when the licensed practitioner determines the condition can improve significantly within one month or the services are needed to set up a safe maintenance program, the services treat a specific illness or injury, and the care follows an ongoing written plan of care. Supervised PT is not medically necessary once therapeutic benefit has been achieved, sports rehabilitation is not covered, and listed methods such as Kinesio taping are considered experimental, investigational, or unproven.
Effective January 1, 2020, procedure codes 97129 and 97130 replaced G0515 for cognitive skills development, and claims with G0515 for dates of service on or after that date will deny. Procedure codes 20560 and 20561 replace 97799 for dry needling, and the Provider Services Call Center changed its hours effective February 5, 2020. The bulletin also set a swing bed rate of $234.34 effective January 1, 2020, added Youth Day Services for ages 12 to 17 on the HCBS-CES waiver, and warned that certain NDCs from First Databank may not be payable after March 31, 2020.
This WA and Alaska medical policy and coding update lists changes with effective dates from February 1, 2020 through July 2, 2020. For dates of service July 2, 2020 and after, the plan will begin using InterQual criteria to review services under policy 10.01.531, which replaces the listed medical policies including Hip Arthroplasty in Adults and Knee Arthroplasty in Adults. Coding updates list code 55874 as requiring review for medical necessity and prior authorization effective February 9, 2020, and code J2350 as requiring review for site of service as part of medical necessity and prior authorization effective March 5, 2020.
Effective June 1, 2020, Otrexup, Rasuvo, Trexall and Xatmep were added to the new Folate Antimetabolites policy, and Braftovi with Erbitux was added for metastatic colorectal cancer with a BRAF V600E mutation in adults. H-wave stimulation and the Cefaly headband were added to investigational services under the Electrical Stimulation Devices policy, and the surgical treatment of snoring and obstructive sleep apnea policy was renumbered to 7.01.101 and replaced policy 7.01.554. Coding updates made CPT 0507T subject to investigative review, required medical necessity and prior authorization review for HCPCS J9145, G2082 and G2083, removed that review for CPT 97129, 97130 and 27445, and required medical necessity review for SARS-CoV-2 serology CPT 86328 and 86769 starting May 27, 2020.
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.
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