CommercialCoverageHigh impact
Applied Behavior Analysis (CPB 0554, reviewed 2025-11-26)
Aetna·Pediatrics, Psychiatry, Neurology·Medical Policy
Effective date
Nov 26, 2025
We identified it
Aug 17, 2026
Summary
Aetna has clarified its Applied Behavior Analysis (ABA) coverage policy, designating ABA as experimental/investigational for Down Syndrome without autism co-morbidity and all non-ASD indications. ABA remains covered only for autism spectrum disorder (ASD) diagnoses. Billing teams must ensure claims for ABA services (CPT 97151-97158) are only submitted with qualifying ASD diagnoses (ICD-10 F84.0-F84.9) and deny or reject claims for Down Syndrome (Q90.0-Q90.9) or other non-ASD conditions.
Action Required
Immediately (effective 2025-11-26): Billing team must implement the following controls in billing software: (1) Block or flag for denial all claims for CPT codes 97151-97158 and 0362T, 0373T when paired with ICD-10 diagnosis codes Q90.0-Q90.9 (Down Syndrome); (2) Block or flag for denial all ABA procedure codes when submitted with ICD-10 diagnoses other than F84.0-F84.9 (ASD); (3) Configure system to require ICD-10 code F84.0-F84.9 as primary or co-diagnosis for all ABA claims on Aetna plans; (4) Update claim submission rules to automatically deny claims not meeting these criteria. Providers and clinical staff must update documentation templates and encounter forms to clearly document autism spectrum disorder diagnosis for any ABA services. Billing team must communicate policy change to front desk/scheduling staff to flag patient charts during pre-authorization calls. Failure to implement these controls will result in claim denials and potential recoupment of erroneously paid claims.