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Applied Behavior Analysis (CPB 0554, reviewed 2025-11-26)
Effective date
Not stated in the notice
Identified
Aug 17, 2026
Summary
Aetna considers applied behavior analysis (ABA) experimental, investigational, or unproven for Down syndrome in the absence of an autism spectrum disorder (ASD) comorbidity and for all other non-ASD indications. CPT 97151 through 97158 (adaptive behavior assessment and treatment) are not covered for the indications listed. ABA for autism is covered for ICD-10 codes F84.0 through F84.9 when selection criteria are met, and Down syndrome codes Q90.0 through Q90.9 are not covered for the indications listed.
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What to do
Action · 6 steps
01Billing team: Do not bill ABA for Down syndrome without a co-occurring autism spectrum disorder diagnosis, or for other non-ASD indications, because the policy considers them experimental, investigational, or unproven.
02Claims for CPT 97151 through 97158 are not covered for the indications listed, and Down syndrome (ICD-10 Q90.0 through Q90.9) is not covered for the indications listed.
03Bill ABA for autism with an ICD-10 code from F84.0 through F84.9 when selection criteria are met.
04CPT 0362T and 0373T apply to services with all of these components: administration by an on-site physician or other qualified health care professional, assistance of two or more technicians, a patient who exhibits destructive behavior, and an environment customized to the patient's behavior.
05When ABA is provided with inpatient, residential or partial hospitalization care, coverage is determined using the medical necessity criteria for that level of care.
06ABA is generally provided for a defined period, so document measurable improvement in targeted behaviors and functional outcomes before services continue, and watch for a separate ABA-specific review in the outpatient setting or at transition from a higher level of care.
Codes mentioned
9715197158F84.0F84.9Q90.0Q90.9
Original notice
Applied Behavior Analysis (CPB 0554, reviewed 2025-11-26)
aetna.com · Always check the source before changing claims.
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