CommercialCoverageHigh impact
Attention Deficit/Hyperactivity Disorder (CPB 0426, reviewed 2026-07-07)
Aetna·Psychiatry, Pediatrics, Internal Medicine +2 more·Medical Policy
Effective date
Jul 7, 2026
We identified it
Aug 12, 2026
Summary
Aetna's updated ADHD policy (CPB 0426, effective 2026-07-07) clarifies covered assessment and treatment services while explicitly excluding numerous experimental and unproven diagnostic and therapeutic interventions. The policy reaffirms coverage for psychiatric evaluation, medical workup, and pharmacotherapy/behavioral modification, but denies coverage for neuropsychological testing in uncomplicated cases, all forms of neurofeedback, computerized attention testing, and numerous complementary therapies. Billing teams must ensure claims align with the covered services list and deny or appeal claims for excluded procedures.
Action Required
By 2026-07-07: Billing team must update claim scrubbing rules in billing software to enforce Aetna ADHD policy coverage limitations. REQUIREMENTS: (1) Flag and DENY claims for explicitly excluded procedures including neurofeedback/EEG biofeedback, computerized attention tests (Gordon Diagnostic System, Quotient ADHD system), neuropsychological testing for uncomplicated ADHD cases (96132, 96133, 96136, 96137), educational testing, occupational therapy, physical therapy, speech therapy, and all complementary therapies listed (acupuncture, chiropractic, herbal remedies, etc.). (2) ALLOW claims for covered codes: 90791, 90792 (psychiatric evaluation), 96116, 96121 (neurobehavioral status exam) when medically necessary per policy criteria. (3) Update prior authorization templates to require documentation distinguishing complicated vs. uncomplicated ADHD cases before approving neuropsychological testing. (4) Providers must document on encounter forms: presence/absence of focal neurological signs, seizure history, head trauma, or learning disability differential before billing neuropsych codes. (5) Claims lacking this documentation should be denied with explanation of medical necessity requirements. Consequences: Claims for excluded services will be denied; claims for neuropsych testing without proper documentation will be denied; improper billing may result in overpayment recovery.