Description
Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood neurobehavioral disorders. Approximately eight to ten percent of school age children are diagnosed with ADHD, with males predominantly more affected than females. Often, an individual with ADHD is affected by comorbidities, which are other conditions that exist simultaneously with and independent of ADHD. Examples include, but may not be limited to, anxiety disorder, conduct disorder, depression, oppositional defiant disorder and learning disabilities. Although ADHD is usually diagnosed in childhood, it may last into adulthood or be diagnosed at any age.

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

ADHD behavior may generally be classified into three subtypes: predominantly inattentive, predominately hyperactive-impulsive or a combination of the two.

ADHD is characterized by a pattern of behavior, present in multiple settings (e.g., school, home), that can result in performance issues in social, educational and/or work settings. There is no single test to diagnose ADHD. Typically, a diagnosis is made by a comprehensive exam that assesses the onset and course of symptoms consistent with ADHD. A functional assessment, if conducted, evaluates both the severity of impairment and the pervasiveness of symptoms occurring in different environments.

The parameters for diagnosing ADHD are found in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA). The DSM-5 includes a set of diagnostic criteria that indicate the symptoms that must be present to establish the diagnosis of ADHD.

There are several types of specialists qualified to diagnose and treat ADHD. Examples include, but may not be limited to, child psychiatrists, family physicians, neurologists, pediatricians, or psychiatrists. Although several types of treatments have been explored for ADHD, medication and behavior modification are generally considered the most common and effective.

For information regarding proposed treatments for ADHD not addressed in this policy, please see the following Medical Coverage Policies:

• Chiropractic manipulation - Chiropractic Care
• Cognitive rehabilitation - Cognitive Rehabilitation
• Complementary or alternative medicine practices - Complementary and Alternative Medicine
• Interactive metronome therapy - Physical Therapy and Occupational Therapy
• Neurofeedback (EEG biofeedback) - Biofeedback
• Sensory integration therapy - Physical Therapy and Occupational Therapy
• Transcranial magnetic stimulation - Transcranial Magnetic Stimulation and Cranial

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Any services for ADHD diagnosis and/or treatment that are considered primarily educational or training in nature may be excluded by certificate.

Please consult the member’s individual certificate regarding Plan coverage. Any state mandates for ADHD diagnosis and/or treatment take precedence over this medical coverage policy. Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of ADHD.

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

Diagnosis and Evaluation

Humana members may be eligible under the Plan for the following services for the diagnosis and evaluation of ADHD:

• Interview (individual or child and parent/guardian), which may include obtaining information about daycare, school or work functioning utilizing DSM-5 criteria. May also include an evaluation of comorbid psychiatric disorders and review of the individual’s family and social history; AND
• Complete medical history and physical examination, including specific laboratory evaluation (complete blood count [CBC], liver function tests [LFTs]) and a cardiac evaluation and screening incorporating an electrocardiogram (ECG) if indicated, prior to beginning stimulant medication therapy7,8,32

Treatment

Humana members may be eligible under the Plan for the treatment of ADHD utilizing the following services:

• Behavior modification (refer to behavioral health benefit); AND/OR
• Pharmacological treatment (refer to pharmacy benefit)

Coverage Limitations

Diagnosis and Evaluation

Humana members may NOT be eligible under the Plan for diagnosis and evaluation of ADHD by any methods other than those listed above including, but may not be limited to, the following:

• Actigraphy; OR
• Computer-based/continuous performance test (eg, Gordon Diagnostic System, QbCheck, QbTest, Test of Variables of Attention [TOVA]); OR
• Computerized electroencephalography (EEG) including, but may not be limited to, the following:
  • Brain mapping; OR
  • Computer based EEG systems; OR
  • Neuropsychiatric EEG-based assessments (NEBA); OR
  • Quantitative electroencephalography (QEEG); OR
• EEG; OR
• Hair analysis; OR
• Measurement of lead levels, unless the individual has been identified as having one or more risk factors through the use of a childhood lead poisoning screening questionnaire; OR
• Measurement of thyroid hormone levels, unless the individual exhibits clinical manifestations of hyperthyroidism (eg, modest acceleration of linear growth and epiphyseal maturation, weight loss or failure to gain weight, excessive retraction of the eyelids causing lid lag and stare, diffuse goiter, tachycardia and increased cardiac output, increased gastrointestinal motility, tremor, hyperreflexia); OR
• Neuroimaging, such as computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), positron emission tomography (PET), single-photon emission computed tomography (SPECT); OR
• Neuropsychological testing for unremarkable or uncomplicated cases of ADHD

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Treatment

Humana members may NOT be eligible under the Plan for treatment of ADHD by any methods other than those listed above including, but may not be limited to, the following:

• Application-based games for use with smart phone or tablet (eg, EndeavorRX); OR
• Cognitive behavioral therapy; OR
• Dietary counseling/dietary modification (eg, Feingold diet); OR
• Dore program/dyslexia dyspraxia attention treatment (DDAT); OR
• External trigeminal nerve stimulation (eTNS) (eg, Monarch, Smile); OR
• Vision therapy (some components of vision therapy [eg, orthoptics, vision training] may be excluded by certificate)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about ADHD may be found from the following websites:

• Centers for Disease Control and Prevention
• Children and Adults with Attention Deficit/Hyperactivity Disorder
• National Institute of Mental Health
• National Library of Medicine

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 6 of 26

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

• CPT® Code(s): 64999
• Description: Unlisted procedure, nervous system
• Comments: Not Covered if used to report the treatment of ADHD

• CPT® Code(s): 70450
• Description: Computed tomography, head or brain; without contrast manne graphy,
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• CPT® Code(s): 70460
• Description: Computed tomography, head or brain; with contrast material(s)
• Comments: Not Covered if used to | report the diagnosis and evaluation of ADHD

• CPT® Code(s): 70470
• Description: Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• CPT® Code(s): 70496
• Description: Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• CPT® Code(s): 70544
• Description: Magnetic resonance angiography, head; without contrast material(s) Blograpny,
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• CPT® Code(s): 70545
• Description: Magnetic resonance angiography, head; with contrast material(s) glography,
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• CPT® Code(s): 70546
• Description: Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 7 of 26

this is the current version before utilizing.

Magnetic Resonance Imaging Codes

• Code: 70591
• Description: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 70552
• Description: Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(e) ane
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 70553
• Description: Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 70554
• Description: Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 70555
• Description: Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 76390
• Description: Magnetic resonance spectroscopy
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 78600
• Description: Brain imaging, less than 4 static views;
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 78601
• Description: Brain imaging, less than 4 static views; with vascular flow
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 78605
• Description: Brain imaging, minimum 4 static views;
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 78606
• Description: Brain imaging, minimum 4 static views; with vascular flow
• Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 8 of 26

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 78609
  Description: Brain imaging, positron emission tomography (PET); perfusion evaluation
• Code: 80076
  Description: Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450)
• Code: 82308
  Description: Calcitonin
• Code: 83655
  Description: Lead
• Code: 84436
  Description: Thyroxine; total
• Code: 84437
  Description: Thyroxine; requiring elution (eg, neonatal)
• Code: 84439
  Description: Thyroxine; free
• Code: 84442
  Description: Thyroxine binding globulin (TBG)
• Code: 84443
  Description: Thyroid stimulating hormone (TSH)
• Code: 84445
  Description: Thyroid stimulating immune globulins (TSI)

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 9 of 26

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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Code: 84481
  Description: Triiodothyronine T3; free
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 85025
  Description: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
  Comments:
• Code: 85027
  Description: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
  Comments:
• Code: 86800
  Description: Thyroglobulin antibody
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 90791
  Description: Psychiatric diagnostic evaluation
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 90792
  Description: Psychiatric diagnostic evaluation with medical services
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 90832
  Description: Psychotherapy, 30 minutes with patient
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 90833
  Description: Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 90834
  Description: Psychotherapy, 45 minutes with patient
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 90836
  Description: Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 10 of 26

this is the current version before utilizing.

• Code: 90837
  Description: Psychotherapy, 60 minutes with patient
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 90838
  Description: Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 92065
  Description: Orthoptic and/or pleoptic training, with continuing medical direction and evaluation
  Comments: Not Covered
• Code: 95700
  Description: Electroencephalogram (EEG) continuous recording, with video when performed, setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum of 8 channels
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 95705
  Description: Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; unmonitored
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95706
  Description: Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; with intermittent monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95707
  Description: Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95708
  Description: Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95709
  Description: Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95710
  Description: Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 12-26 hours; with continuous, real-time monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 11 of 26

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• Code: 95711
  Description: Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95712
  Description: Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with intermittent monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95713
  Description: Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95714
  Description: Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95715
  Description: Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95716
  Description: Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous, real-time monitoring and maintenance
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95717
  Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; without video
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Not Covered if used to report the diagnosis and evaluation of ADHD

• Code: 95718
  Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG)
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 95719
  Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, interpretation and report for periods greater than 12 hours, up to 26 hours of EEG recording; without video
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 12 of 26

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Code: 95721
Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, without video
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 95722
Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG)
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 95723
Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG recording, without video
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 95724
Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG)
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 95725
Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 13 of 26

Code: 95726
Description: Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG recording, with video (VEEG)
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 95803
Description: Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)
Comments: Not Covered

Code: 95812
Description: Electroencephalogram (EEG) extended monitoring; 41-60 minutes
Comments: Not Covered if used to report any test outlined in Coverage Limitations section

Code: 95813
Description: Electroencephalogram (EEG) extended monitoring; 61-119 minutes
Comments: Not Covered if used to report any test outlined in Coverage limitations section

Code: 95822
Description: Electroencephalogram (EEG); recording in coma or sleep only
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 95957
Description: Digital analysis of electroencephalogram (EEG) (eg, for epileptic 5 a anal x) P 8 (EEG) (eg, piep P ¥
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 96020
Description: Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 96112
Description: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour
Comments: Coverage is subject to the provision of the applicable behavioral health benefit

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
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• Code: 96113
  Description: Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure)
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 96116
  Description: Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour
  Comments: Not Covered if used to report Continuous Performance Testing for the diagnosis and evaluation of ADHD
• Code: 96121
  Description: Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure)
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 96125
  Description: Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 96127
  Description: Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
  Comments:

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
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Code: 96130
Description: Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
Comments: Not Covered if used to report the diagnosis and

Code: 96131
Description: Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure)
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 96132
Description: Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and a wo . ; clinical data, clinical decision making, treatment planning and . F . . report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
Comments: Not Covered if used to . . report the diagnosis and . evaluation of ADHD

Code: 96133
Description: Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure)
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 96136
Description: Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes
Comments: Not Covered if used to report the diagnosis and evaluation of ADHD

Code: 96137
Description: ea aan ae, 8 by Phy q P ’ two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure)
Comments: | Not covered if used to report the diagnosis and evaluation of ADHD

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
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• Code: 96138
  Description: Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 96139
  Description: Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure)
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 96146
  Description: Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only
  Comments: Not Covered if used to report the diagnosis and evaluation of ADHD
• Code: 96156
  Description: Health behavior assessment, or re-assessment (ie, health- focused clinical interview, behavioral observations, clinical decision making)
  Comments:
• Code: 96158
  Description: Health behavior intervention, individual, face-to-face; initial 30 minutes
  Comments:
• Code: 96159
  Description: Health behavior intervention, individual, face-to-face; each additional 15 minutes (List separately in addition to code for primary service)
  Comments:
• Code: 96164
  Description: Health behavior intervention, group (2 or more patients), face- to-face; initial 30 minutes
  Comments:
• Code: 96165
  Description: Health behavior intervention, group (2 or more patients), face- to-face; each additional 15 minutes (List separately in addition to code for primary service)
  Comments:
• Code: 96167
  Description: Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
  Comments:
• Code: 96168
  Description: Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)
  Comments:
• Code: 96170
  Description: Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
  Comments:
• Code: 96171
  Description: Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (List separately in addition to code for primary service)
  Comments:

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 17 of 26

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• Code: 97129
  Description: Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes
  Comments: Not Covered if used to report the treatment of ADHD
• Code: 97130
  Description: Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)
  Comments:

Not Covered if used to report the treatment of ADHD

• Code: 97151
  Description: Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 97152
  Description: Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Code: 97153
  Description: Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit
• Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes
  Comments: Coverage is subject to the provision of the applicable behavioral health benefit

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
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CPT® Category III Code(s)
Description: No code(s) identified
Comments:

HCPCS Code(s)
Description: Comments:

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 19 of 26

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• A4541: Monthly supplies for use of device coded at e0733 - Not Covered New Code Effective
• A9999: Rectified DME supply or accessory, not otherwise - 01/01/2024 report the treatment of
• E0733: Transcutaneous electrical nerve stimulator for electrical - ADHD Not Covered
• E1399: Stimulation of the trigeminal nerve Durable medical equipment, miscellaneous - New Code Effective 01/01/2024 Not Covered if used to report the treatment of
• K1016: Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve - Not Covered
• K1017: Monthly supplies for use of device coded at k1016 - Not Covered
• P2031: Hair analysis (excluding arsenic) - Not Covered
• S8035: Magnetic source imaging - Not Covered
• S8040: Topographic brain mapping - Not Covered
• S9452: Nutrition classes, nonphysician provider, per session - Not Covered if used to report the treatment of ADHD
• S9470: Nutritional counseling, dietitian visit - Not Covered if used to report the treatment of ADHD
• T1505: Electronic medication compliance management device, includes all components and accessories, not otherwise classified - Not Covered if used to report the treatment of ADHD

References

Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Attention deficit hyperactivity disorder: diagnosis and treatment in children and adolescents. https://www.ahrq.gov. Published January 2018. Accessed May 24, 2023.

American Academy of Allergy, Asthma & Immunology (AAAAI). Food allergy: a practice parameter update – 2014. https://www.aaaai.org. Published November 2014. Accessed May 30, 2023.

American Academy of Child and Adolescent Psychiatry (AACAP). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder (ARCHIVED). https://www.aacap.org. Published July 2007. Accessed May 24, 2023.

American Academy of Neurology (AAN). Practice Advisory. The utility of EEG theta/beta power ratio in ADHD diagnosis. https://www.aan.com. Published October 2016. Updated October 22, 2022. Accessed May 31, 2023.

American Academy of Ophthalmology (AAO). Policy Statement. Learning disabilities, dyslexia and vision. A joint statement of the American Academy of Pediatrics (Section on Ophthalmology, Council on Children with Disabilities), the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus and the American Association of Certified Orthoptists. https://www.aao.org. Published 1984. Updated July 2014. Accessed May 30, 2023.

American Academy of Pediatrics (AAP). Clinical Practice Guideline. Clinical practice guideline for the diagnosis, evaluation and treatment of attention- deficit/hyperactivity disorder in children and adolescents. https://www.aap.org. Published October 2019. Accessed May 31, 2023.

American College of Cardiology (ACC). JACC Review Topic of the Week. Cardiovascular effects of ADHD therapies. https://www.acc.org.

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
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American Psychiatric Association (APA). Attention-deficit/hyperactivity disorder. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association; 2013: 59-66.

10. ClinicalKey. Benson NM, Restrepo JA. Attention deficit/hyperactivity disorder. In: Beach S, Christian C, DaSilva M, Ferri F, et al. Ferri’s Clinical Advisor 2023. Elsevier; 2023:226-228.e1. https://www.clinicalkey.com. Accessed May 26, 2023.
11. ClinicalKey. Clinical Overview. Attention-deficit hyperactivity disorder. https://www.clinicalkey.com. Updated December 19, 2022. Accessed May 26, 2023.
12. ECRI Institute. Clinical Evidence Assessment. EndeavorRX (Akili Interactive Labs, Inc.) interactive cognitive training software for treating attention- deficit/hyperactivity disorder in children. https://www.ecri.org. Published July 23, 2020. Accessed May 23, 2023.
13. ECRI Institute. Clinical Evidence Assessment. Quantitative electroencephalography mapping for diagnosing attention deficit/ hyperactivity disorder. https://www.ecri.org. Published October 21, 2021. Accessed May 23, 2023.
14. ECRI Institute. Hotline Response (ARCHIVED). Continuous performance tests for diagnosing attention deficit hyperactivity disorder in children. https://www.ecri.org. Published April 13, 2010. Accessed May 24, 2013.
15. ECRI Institute. Hotline Response (ARCHIVED). Magnetic resonance imaging for diagnosing autism and attention deficit hyperactivity disorder. https://www.ecri.org. Published December 28, 2011. Accessed May 23, 2023.
16. ECRI Institute. Hotline Response (ARCHIVED). Role of actigraphy in evaluating attention deficit hyperactivity disorder in children. https://www.ecri.org. Published May 2, 2008. Updated January 8, 2014. Accessed May 23, 2023.
17. ECRI Institute. Hotline Response (ARCHIVED). Single photon emission computed tomography for diagnosing mental health disorders in children.https://www.ecri.org. Published June 16, 2006. Updated October 29, 2012. Accessed May 23, 2023.

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
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Goode AP, Coeytaux RR, Maslow GR, et al. Nonpharmacologic treatments for attention-deficit/hyperactivity disorder: a systematic review. Pediatrics. 2018;141(6):e1-14. https://www.aap.org. Accessed June 19, 2018.

• Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). QbTest (Qbtech) for diagnosis of attention-deficit hyperactivity disorder. https://evidence.hayesinc.com. Published December 18, 2019. Accessed May 16, 2022.
• Hayes, Inc. Evolving Evidence Review. EndeavorRx (Akili Interactive Labs Inc.) for treatment of attention-deficit/hyperactivity disorder in children. https://evidence.hayesinc.com. Published January 18, 2023. Accessed May 24, 2023.

Attention Deficit Hyperactivity Disorder Diagnosis and Treatment

Effective Date: 01/01/2024
Revision Date: 01/01/2024
Review Date: 06/22/2023
Policy Number: HUM-0340-036
Page: 23 of 26

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• Monarch eTNS system (NeuroSigma Inc.) for treatment of attention deficit/hyperactivity disorder in children. https://evidence.hayesinc.com. Published February 9, 2023. Accessed May 24, 2023.
• Hayes, Inc. Health Technology Brief (ARCHIVED). Quotient ADHD system (BioBehavioral Diagnostics Company [BioBDx]) for diagnosis of attention- deficit/hyperactivity disorder. https://evidence.hayesinc.com. Published May 31, 2011. Updated May 23, 2013. Accessed May 24, 2023.
• Hayes, Inc. Medical Technology Directory (ARCHIVED). Cognitive-behavior therapy for the treatment of attention-deficit/hyperactivity disorder (ADHD) in adults. https://evidence.hayesinc.com. Published February 15, 2011. Updated February 6, 2015. Accessed May 24, 2023.
• Hayes, Inc. Medical Technology Directory (ARCHIVED). Neuropsychological testing for attention-deficit/hyperactivity disorder. https://evidence.hayesinc.com. Published May 23, 2008. Updated May 15, 2012. Accessed May 24, 2023.
• Hayes, Inc. Medical Technology Directory (ARCHIVED). Parent training for children with attention-deficit/hyperactivity disorder.
  Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
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  Revision Date: 01/01/2024
  Review Date: 06/22/2023
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  https://evidence.hayesinc.com. Published September 10, 2010. Updated August 6, 2014. Accessed May 24, 2023.
• MCG Health. Emerging Guidelines Preview. EEG, quantitative (brain mapping). https://www.mcg.com. Published November 4, 2022. Accessed May 24, 2023.
• Society for Developmental & Behavioral Pediatrics (SDBP). Clinical practice guideline for the assessment and treatment of children and adolescents with complex attention-deficit/hyperactivity disorder. https://www.sdbp.org. Published February/March 2020. Accessed May 24, 2023.
• UpToDate, Inc. Attention deficit hyperactivity disorder in adults: epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. https://www.uptodate.com. Updated April 2023. Accessed May 23, 2023.
• UpToDate, Inc. Attention deficit hyperactivity disorder in children and adolescents: clinical features and diagnosis. https://www.uptodate.com. Updated April 2023. Accessed May 23, 2023.
• UpToDate, Inc. Attention deficit hyperactivity disorder in children and adolescents: epidemiology and pathogenesis. https://www.uptodate.com. Updated April 2023. Accessed May 23, 2023.
• UpToDate, Inc. Attention deficit hyperactivity disorder in children and adolescents: overview of treatment and prognosis. https://www.uptodate.com. Updated May 16, 2023. Accessed May 23, 2023.
• UpToDate, Inc. Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder. https://www.uptodate.com. Updated April 2023. Accessed May 23, 2023.
• UpToDate, Inc. Clinical manifestations and diagnosis of Graves disease in children and adolescents. https://www.uptodate.com. Updated April 2023. Accessed May 23, 2023.
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• Attention Deficit Hyperactivity Disorder Diagnosis and Treatment
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Appendix A DSM-5 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

1. Either 1 or 2:
   1. Five or more (17 years of age or older) or six or more (under 17 years of age) of the following symptoms of inattention have been present for at least six months to a point that is disruptive and inappropriate for developmental level:
      • Inattention
      • Often does not give close attention to details or makes careless mistakes in schoolwork, work or other activities
      • Often has trouble keeping attention on tasks or play activities
      • Often does not seem to listen when spoken to directly
      • Often does not follow instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
      • Often has trouble organizing tasks and activities
      • Often avoids, dislikes or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework)
      • Often loses things needed for tasks and activities (eg, toys, school assignments, pencils, books or tools)
      • Is often easily distracted
      • Is often forgetful in daily activities
   2. Five or more (17 years of age or older) or six or more (under 17 years of age) of the following symptoms of hyperactivity-impulsivity have been present for at least six months to an extent that is disruptive and inappropriate for developmental level:
      • Hyperactivity-impulsivity
      • Often fidgets with hands or feet or squirms in seat
      • Often gets up from seat when remaining in seat is expected
      • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless)
      • Often has trouble playing or enjoying leisure activities quietly (in adolescents or adults this may be reported as feeling restless)
      • Often seems on the go or often acts as if driven by a motor
      • Often talks excessively
      • Often blurts out answers before questions have been finished
      • Often has trouble waiting one’s turn
      • Often interrupts or intrudes on others (eg, butts into conversations or games)
2. Some symptoms that cause impairment were present before age 12 years
3. Some impairment from the symptoms is present in two or more settings (eg, at school/work and at home)
4. There must be clear evidence of significant impairment in social, school or work functioning
5. DSM-5 includes no exclusion criteria for people with autism spectrum disorder, since symptoms of both disorders co-occur. However, ADHD symptoms must not occur exclusively during the course of schizophrenia or another psychotic disorder and must not be better explained by another mental disorder, such as a depressive or bipolar disorder, anxiety disorder, dissociative disorder, personality disorder or substance intoxication or withdrawal

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