Aetna psychological testing coverage: codes
The short answerAetna covers psychological and neuropsychological testing (96130 to 96139, 96146) only when its medical necessity criteria are met. Educational, employment, disability and legal testing is not covered. Testing for uncomplicated ADHD is rarely necessary, and neurodiversity assessment is considered not medically necessary.
By Javier Alvarez · Updated · 1 min read
1 row: Aetna. Public policy, not the member's benefits.
Aetna
Aetna Clinical Policy Bulletin 0158 Neuropsychological and Psychological Testing · All states
| 96116 | Listed (covered if the selection criteria in the bulletin are met) [1] |
|---|---|
| 96121 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96130 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96131 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96132 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96133 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96136 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96137 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96138 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96139 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| 96146 | Listed (covered if the selection criteria in the bulletin are met) [1] |
| Where it applies | Testing is medically necessary when the hours requested do not exceed the reasonable time needed for the clinical question, the techniques are validated for the diagnostic question, age and population, are not redundant, and are the most updated version of the instrument. Pre-surgical clearance testing is generally not medically necessary. Testing for a mental health diagnosis falls under the mental health benefit; testing for a medical diagnosis such as TBI, stroke, epilepsy or Alzheimer's falls under the medical benefit. [1] |
| Diagnoses | Neuropsychological testing can distinguish ADHD from learning disabilities or language disorders when that remains unclear after history and exam, and may be necessary for neurologically complicated ADHD. It is rarely necessary for uncomplicated ADHD. It is not medically necessary for chronic fatigue syndrome or migraine, or when the member is actively abusing substances. [1] |
| Also | Autism testing follows CPB 0648. Diagnostic assessment for neurodiversity is considered not medically necessary. Testing for educational reasons is not covered because school systems usually provide it, and testing for employment, disability qualification or legal purposes is not covered. Computerized devices such as Cognitrax are experimental for screening healthy people. [1] |
What Aetna's documents say
The table above has every field we found for Aetna, with numbered sources. In short:
- Where it applies. Testing is medically necessary when the hours requested do not exceed the reasonable time needed for the clinical question, the techniques are validated for the diagnostic question, age and population, are not redundant, and are the most updated version of the instrument. Pre-surgical clearance testing is generally not medically necessary. Testing for a mental health diagnosis falls under the mental health benefit; testing for a medical diagnosis such as TBI, stroke, epilepsy or Alzheimer's falls under the medical benefit.
- Codes. 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139 and 96146 are listed.
Psychological testing coverage at other national payers
Medicare (national), UnitedHealthcare and Optum Behavioral, Cigna and Evernorth and Carelon Behavioral Health.
Check Aetna's claim against the row
Before the claim goes out, compare it with the row above: the evaluation and administration codes pair the way the policy says, the hours fit any cap, the referral question is documented, and prior authorization covers the units. The psychological testing table compares Aetna with every other payer we checked.