ICD-10 F05 is officially defined as "Delirium due to known physiological condition." code F05 is referenced in 4 tracked payer policy changes from Humana and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code F05 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Humana Louisiana Medicaid has implemented a new antipsychotic utilization program requiring prior authorization for antipsychotic medications prescribed to patients with documented dementia diagnoses. The program includes strict age-based criteria and specific compendia-supported indications for approval.
Aetna considers intraoperative scalp EEG medically necessary for monitoring cerebral function during carotid artery surgery, during intracranial vascular surgical procedures, and during parietal tumor resection or resection of a lesion near the eloquent cortex. Grid monitoring (electrocorticography) to determine the location of the epileptogenic focus for possible surgical resection is medically necessary for members with intractable seizures when seizures arise from functionally important brain areas, when surface EEG did not adequately localize the epileptogenic area, or when electrophysiological localization is discordant with other neurodiagnostic studies suggesting an abnormality in more than one region of the brain. EEG monitoring during WADA testing is medically necessary, while intraoperative EEG for open-heart surgery and grid monitoring for all other indications not listed are experimental, investigational, or unproven.
Aetna considers quantitative pupillometry and pupillography experimental, investigational, or unproven for all indications, including the following: intracranial pressure monitoring, pain assessment, early concussion assessment, Parkinson disease, Alzheimer's disease, heart failure, depression, prediction of outcome after cardiac arrest, and glaucoma, because its effectiveness has not been established. Chromatic pupillography is considered experimental, investigational, or unproven for detecting glaucoma, Leber congenital amaurosis, optic nerve diseases, and retinitis pigmentosa, and for evaluating Gaucher disease and hemianopia. CPT 95919 (quantitative pupillometry with physician or other qualified health care professional interpretation and report) is listed as not covered for the indications in this policy.
Magnetic resonance spectroscopy (MRS) is considered medically necessary for specific indications in this policy, including assessing prognosis in hypoxic ischemic encephalopathy, distinguishing low grade from high grade gliomas, and distinguishing recurrent brain tumor from radiation-induced tumor necrosis. MRS is considered experimental, investigational, or unproven for all other indications listed, including breast cancer, prostate cancer, epilepsy, dementia and movement disorders, and traumatic brain injury. CPT 76390 is covered for the listed indications, and CPT codes 0609T, 0610T, 0611T and 0612T are not covered for the indications listed. The policy was last reviewed 03/26/2026.
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