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Tourette's Syndrome (CPB 0480, reviewed 2026-07-24)

Aetna·Neurology, Psychiatry, Pediatrics +1 more·Medical Policy
Effective date
Jul 24, 2026
We identified it
Aug 18, 2026
Days to comply

Summary

Aetna updated its Tourette's Syndrome clinical policy (CPB 0480) establishing medical necessity criteria and clearly delineating covered versus experimental/investigational treatments. Covered services include behavioral intervention (CBIT), specific pharmacotherapies, psychotherapy, and limited assessment tools (EEG/neuro consult only with focal signs). Most advanced interventions including deep brain stimulation, transcranial stimulation, neuroimaging, and biomarker testing are classified as experimental and not covered. Billing teams must immediately align claims submission and prior authorization processes to this framework.

Action Required

Action needed
IMMEDIATE (by July 31, 2026): Billing team must implement claim processing updates for Aetna Tourette's Syndrome cases: (1) REQUIRE prior authorization for all covered services (CBIT, psychotherapy CPT 90832-90840, EEG 95812-95830, E&M 99201-99215) using CPB 0480 selection criteria validation (multiple motor + vocal tics, >1 year duration, onset <age 18, no substance/medical cause); (2) DENY or redirect to experimental review all claims for CPT codes 0042T, 0648T, 0649T, 61735, 61863-61868, 61880, 61885-61888, 64612, 64616-64617, and 70450, 70460, 70470, 70472-70473, 70496 when used for Tourette's diagnosis/treatment; (3) UPDATE billing software and encounter forms to flag Tourette's cases for medical necessity documentation review before claim submission; (4) COMMUNICATE to neurology, psychiatry, and behavioral health providers that pharmacotherapy (aripiprazole, clonazepam, clonidine, haloperidol, pimozide, risperidone, tetrabenazine, tricyclic antidepressants) coverage requires referral to pharmacy benefit plan, not medical billing; (5) DOCUMENT that educational interventions are non-covered under most Aetna plans and should not be billed. Failure to implement prior authorization requirements will result in claim denials; submission of experimental codes without proper denial management will trigger audit liability.

Affected Billing Codes

90785
90832
90838
90839
90840
95812
95813
95814
95815
95816
95819
95822
95824
95826
95827
95830
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
61735
61863
61864
61867
61868
61880
61885
61886
61888
64612
64616
64617
70450
70460
70470
70472
70473
70496