S8035, Magnetic source imaging
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Document rationale and baseline measures if pursuing complementary or investigational therapies (neurofeedback, dietary interventions, supplementation) and obtain informed consent discussing limited evidence and uncertainties.
- When pharmacologic therapy is used, document medication trials, doses, response and adverse effects where relevant (discussion of stimulants, atomoxetine, bupropion, TCAs appears in the evidence review).
- EndeavorRx: requirement implied in indication — documentation of patient age (8 to 12 years), ADHD subtype (primarily inattentive or combined-type), and a "demonstrated attention issue" measurable by computer-based testing (e.g., baseline computer-based attention testing).
- AKL-T01 (as studied): documentation used in trials included psychiatric screening, ADHD ratings, baseline neuropsychological measures, and objective attentional performance measures such as the TOVA Attention Performance Index (API) with trial inclusion requiring TOVA API ≤ -1.8.
Key Coverage Criteria
- "EndeavorRx is a digital therapeutic (video game-based) indicated to improve attention function as measured by computer-based testing in children aged 8 to 12 years with primarily inattentive or combined-type ADHD, who have a demonstrated attention issue."
- EndeavorRx: "should be considered for use as part of a therapeutic program that may include clinician-directed therapy, medication, and/or educational programs, which further address symptoms of the disorder."
- AKL-T01 (investigational digital therapeutic): indicated in study context to target attention and cognitive control in pediatric patients with ADHD (studied in children aged 8 to 12 years in STARS-ADHD RCT and aged 8 to 14 in adjunct study STARS-Adjunct).
- AKL-T01 (study-specified objective inclusion): pediatric patients with confirmed ADHD and TOVA Attention Performance Index (API) scores of -1.8 and below (STARS-ADHD trial).
- Extended-release methylphenidate: discussed as the "recommended 1st-line pharmacological treatment" for adults with ADHD (Cochrane review examined extended-release formulations in adults diagnosed with ADHD).
- Tryptophan modulation: investigated in clinical trials for effects on ADHD-related symptoms (evidence insufficient; trials mainly used acute tryptophan depletion procedures).
7 Active Policies
ANTHEM-CG-MED-76, CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
AETNA-CPB-0426, Attention Deficit/Hyperactivity Disorder
AETNA-CPB-0279, Magnetic Source Imaging/Magnetoencephalography
CIGNA-0447, Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment
EVICORE-HPLAN-AETNA-5BB4F6E94100
Related Codes
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