HCPCS A9291 is officially defined as "Prescription digital cognitive and/or behavioral therapy, fda cleared, per course of treatment." HCPCS A9291 is referenced in 12 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Independence Blue Cross, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS A9291 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Multiple medical policies are changing effective February 1, 2026, with significant coverage expansions for cardiovascular biomarker testing (CPT 85384, 85385) and bronchial valves, plus numerous additions of covered ICD-10 codes across various services. Several prior authorization requirements are shifting to online authorization tools while some digital health therapies are moving from not medically necessary to contract exclusions.
Several prior authorization and coverage changes for Medicare Advantage plans and commercial products took effect October 1, 2025 and November 1, 2025, and both dates are already effective as of the analysis date of 2026-11-05. Some CPT/HCPCS codes changed from requiring prior authorization to being covered, including IMRT and stereotactic body radiation therapy codes. Prior authorization was added for CPT 25447 and for CPT 22585, 22840 and 27280 for Medicare Advantage plans, and it was removed for CPT 63663 and 63664.
Independence Blue Cross Medicare Advantage added HCPCS code G0685 (algorithm-based autism spectrum disorder assessment via eye-gaze technology) to policy MA12.011g effective 10/01/2026. However, this code is classified as EXPERIMENTAL/INVESTIGATIONAL and is NOT covered. The policy clarifies that prescription digital therapeutics and mobile-based health management applications require FDA approval, clinical evidence, and specific criteria to be considered medically necessary; most such services remain non-covered.
Independence Blue Cross updated policy 12.00.05g to add HCPCS code G0685 (algorithm-based ASD assessment using eye-gaze data) effective 10/01/2026. This code addition does not imply a full policy review; the policy maintains its stance that prescription digital therapeutics and mobile-based health management applications are experimental/investigational and NOT covered unless they meet strict FDA approval and clinical evidence criteria.
Section 110.8 of the Medicare Benefit Policy Manual is updated to reflect DMEPOS benefit category determinations for the 2025 biannual 1 and 2 Level II HCPCS coding cycles. Each listed code is assigned a benefit category, such as DME, Prosthetic Device, Back Brace, Leg Brace, Prosthetic (Artificial Leg or Arm), Lymphedema Compression Treatment Item, or No Medicare DMEPOS benefit category. This update makes no change in policy.
Independence Blue Cross updated MA12.011f to MA12.011g, adding HCPCS code A9294 (Prescription digital cognitive and/or behavioral therapy, biofeedback, FDA cleared) to the policy effective 04/01/2026. This code is classified as EXPERIMENTAL/INVESTIGATIONAL and is NOT covered under Medicare Advantage plans. Billing teams must ensure this code is not billed or is immediately denied if submitted.
Independence Blue Cross added HCPCS code A9294 (prescription digital cognitive/behavioral therapy with biofeedback, FDA-cleared) to policy 12.00.05f effective 04/01/2026. However, this code remains classified as EXPERIMENTAL/INVESTIGATIONAL and is NOT covered. Billing teams must ensure claims using A9294 are denied and not processed for reimbursement.
Aetna considers FDA approved or cleared fertility awareness apps for contraception, such as Natural Cycles, medically necessary when prescribed by a treating provider, and covers one annual Natural Cycles subscription per benefit period with no additional supplies or services covered. The policy considers prescription digital therapeutics such as reSET, reSET-O, Somryst, SleepioRx and Luminopia One experimental, investigational or unproven because there is insufficient evidence in the published peer-reviewed literature of their effectiveness. HCPCS code A9293 is covered if selection criteria are met, and the codes listed under the policy's not-covered heading are not covered for the indications listed in the policy.
Digital health therapies for individuals with substance use disorders are considered investigational under this policy. The policy lists CPT 98978 and HCPCS A9291, G0552, G0553 and G0554 as investigational codes. The policy history shows HCPCS codes G0552, G0553 and G0554 were added effective 01/01/2025, and the description of CPT 98978 was revised in the 01/01/2026 update.
The use of Freespira is considered investigational for all indications, including treatment of panic disorder and post-traumatic stress disorder (PTSD). The use of NightWare is considered investigational for all indications, including nightmare disorder and nightmares from PTSD. Several prescription digital therapy and digital mental health treatment codes are listed as investigational, including HCPCS A9291, A9294, G0552, G0553 and G0554.
The use of EndeavorRx is considered investigational for all indications, including attention-deficit/hyperactivity disorder (ADHD). EndeavorRx received FDA marketing clearance in April 2020 through the De Novo process, and it is indicated to improve attention function in children ages 8 to 12 with primarily inattentive or combined type ADHD. The policy lists CPT 98978, HCPCS A9291, A9999, G0552, G0553 and G0554 as investigational codes.
Effective November 1, 2023, Premera HMO added Botox (onabotulinumtoxinA) for primary focal axillary or palmar hyperhidrosis in adults, moving that criteria from the Treatment of Hyperhidrosis policy, and added Daxxify (daxibotulinumtoxinA-lanm) for cervical dystonia in adult individuals. Effective November 1, 2023, the hypoglossal nerve stimulation criteria for adults with obstructive sleep apnea increased the body mass index limit from 32 kg/m2 to 40 kg/m2, and concurrent use of Beyfortus (nirsevimab-alip) and Synagis (palivizumab) within the same respiratory syncytial virus season was considered not medically necessary. Effective November 1, 2023, Premera HMO added Lumryz (sodium oxybate) for cataplexy or excessive daytime sleepiness in adults with narcolepsy, and required documentation confirming the diagnosis for Actemra (tocilizumab) when used for cytokine release syndrome.
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