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Applied Behavior Analysis (CPB 0554, reviewed 2026-10-14)
Effective date
Not stated in the notice
Identified
Oct 28, 2026
Summary
Aetna's Clinical Policy Bulletin 0554 on applied behavior analysis (ABA) says Aetna considers ABA experimental, investigational or unproven for Down syndrome in the absence of an autism spectrum disorder (ASD) co-morbidity and for all other non-ASD indications. CPT codes 97151 through 97158 are not covered for the indications listed in the policy. ICD-10 codes F84.0 through F84.9 are covered if selection criteria are met, and ICD-10 codes Q90.0 through Q90.9 (Down syndrome) are not covered for the indications listed.
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What to do
Action · 5 steps
01Billing team: Do not bill CPT 97151 through 97158 for Down syndrome without a co-occurring autism spectrum disorder, or for any other non-ASD indication, because the policy lists these as not covered for those indications.
02Billing team: Bill ICD-10 F84.0 through F84.9 for ABA only when the selection criteria are met.
03Billing team: Do not bill ICD-10 Q90.0 through Q90.9 (Down syndrome) for the indications the policy lists as not covered.
04Billing team: For ABA provided with inpatient, residential or partial hospitalization care, coverage is based on the medical necessity criteria for that level of care.
05Billing team: Document measurable improvement in targeted behaviors and functional outcomes, because ABA is generally provided for a defined period and continuation depends on that documentation.
Codes mentioned
9715197158F84.0F84.9Q90.0Q90.9
Original notice
Applied Behavior Analysis (CPB 0554, reviewed 2026-10-14)
aetna.com · Always check the source before changing claims.
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