1. Aetna considers certain services medically necessary for the assessment of attention deficit hyperactivity disorder (ADHD):

   1. Parent/child interview
   2. Medical evaluation (complete medical history and physical examination)
   3. Complete psychiatric evaluation (adults)
   4. Measurement of blood lead level
   5. EEG or neurological consult when in the presence of focal signs or clinical findings are suggestive of a seizure disorder or a degenerative neurological condition.

   Notes:
   
   Neuropsychological testing is not considered medically necessary for the clinical evaluation of persons with uncomplicated cases of ADHD. Psychological testing is not considered medically necessary for evaluation of children with uncomplicated cases of ADHD.   In addition, neuropsychological or psychological testing performed solely for educational reasons may be excluded from coverage, as many Aetna benefit plans exclude coverage of educational testing; please check benefit plan descriptions.  Neuropsychological testing may be medically necessary in neurologically complicated cases of ADHD (e.g., post head trauma, seizures). (See CPB 158 - Neuropsychological and Psychological Testing).  
   
   Referral to an outpatient mental health or chemical dependency provider may be medically necessary for the evaluation and comprehensive bio-psychosocial treatment for these disorders in collaboration with primary care physicians and other specialists.

2. Aetna considers the following experimental and investigational for the assessment and treatment of ADHD because the peer reviewed medical literature does not support the use of these procedures/services for this indication.

   1. Assessment:

      1. Hair analysis (see CPB 300 - Hair Analysis)
      2. Measurement of zinc
      3. Computerized EEG (brain mapping or neurometrics (see CPB 221 - Quantitative EEG (Brain Mapping))
      4. Event-related potentials (see CPB 181 - Evoked Potential Studies)
      5. Neuroimaging (e.g., CT, CAT, MRI, PET and SPECT)
      6. Electronystagmography (in the absence of symptoms of vertigo or balance dysfunction)
      7. Tympanometry (in the absence of hearing loss)
      8. Otoacoustic emissions (in the absence of signs of hearing loss) 
      9. Computerized tests of attention and vigilance
      10. Actometer/Actigraph

      11. Education and achievement testing.*

   2. Treatment:

      1. Sensory (auditory) integration therapy (see CPB 256 - Sensory and Auditory Integration Therapy)
      2. Psychopharmaceuticals: lithium, benzodiazepines, and selective serotonin re-uptake inhibitors* 
      3. Anti-motion-sickness medication
      4. Anti-candida-albicans medication
      5. Dietary treatments
      6. Megavitamin therapy (see CPB 388 - Complementary and Alternative Medicine)
      7. Cognitive behavior modification
      8. Educational intervention (e.g., classroom environmental manipulation, academic skills training, and parental training)*
      9. EEG biofeedback (see CPB 132 - Biofeedback)
      10. Herbal remedies (e.g., Bach flower)
      11. Optometric vision training/Irlen lenses
      12. Chiropractic manipulation
      13. Transcranial magnetic stimulation/cranial electrical stimulation (see CPB 469 - Transcranial Magnetic Stimulation and Cranial Electrical Stimulation)
      14. Therapeutic eurythmy (movement therapy)
      15. Homeopathy
      16. Music therapy (see CPB 388 - Complementary and Alternative Medicine)
      17. Yoga (see CPB 388 - Complementary and Alternative Medicine)
      18. Computerized training on working memory (e.g., Cogmed and RoboMemo).* 

* Notes:

• Many Aetna plans exclude coverage of educational interventions. Please check benefit plan descriptions for details.
• Coverage of pharmacotherapies is subject to the member's specific benefits for drug coverage. Please check benefit plan descriptions for details.
• Psychotherapy is covered under Aetna mental health benefits if the member also exhibits anxiety and/or depression.

Attention deficit/hyperactivity disorder (ADHD) is a common condition among children and adolescents, and has been diagnosed with increased frequency in adults. It is characterized by symptoms of inattention and/or hyperactivity/impulsivity that have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. Usually, some symptoms that caused impairment were present before the age of 7 years. Some impairment from the symptoms is present in 2 or more settings (e.g., at home and at school). Other causes of symptoms (e.g., schizophrenia, psychotic disorder, mood disorder, anxiety disorder, or personality disorder) should be ruled out.

There is no specific test for ADHD; its diagnosis is a clinical one. A parent/child interview is the cornerstone in the assessment of ADHD in children and adolescents. It is used to rule out other psychiatric or environmental causes of symptoms. A medical evaluation with a complete medical history and a physical examination is necessary.

According to the American Academy of Child and Adolescent Psychiatry (AACAP)’s Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder, neuropsychological testing of children for the purpose of diagnosing attention deficit / hyperkinetic disorder is not considered necessary, unless there is strong evidence of a possible neurological disorder.  There are few medical conditions which present with ADHD-like symptoms and most patients with ADHD have unremarkable medical histories.  Neuropsychological assessment may be useful in neurologically-complicated cases of attention-deficit/hyperactivity disorder (ADHD); however, such testing does not confirm the diagnosis of ADHD.

In general, attention-deficit disorders are best diagnosed through a careful history and the use of structured clinical interviews and dimensionally-based rating scales.  Most psychologists obtain behavior ratings at home from the parents and at school from the teacher.  Examples of the rating scales commonly used by psychologists are the Achenbach Child Behavior Checklist, Conners Rating Scales, and ADHD Symptoms Rating Scale.

There are insufficient data to support the usefulness of computerized EEG (brain mapping or neurometrics), event-related potentials, neuroimaging, computerized tests of attention and vigilance, or neuropsychological tests (e.g., Test of Variables of Attention, the Continuous Performance Task, the Wisconsin Card-Sorting Test, the matching Familiar figures Test, and the Wechsler Intelligence Scale for Children-Revised). However, neuropsychological testing may be required in neurologically complicated cases of ADHD (e.g., post head trauma, seizures). There are no data to support the use of hair analysis or measurement of zinc.

Medical management of ADHD entails the use of stimulants -- methylphenidate (Ritalin), dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), as well as an amphetamine-dextroamphetamine combination (Adderall). Pemoline (Cylert) is restricted to secondary use because of hepatic dysfunction associated with its use. Tricyclic antidepressants are used for patients who do not respond to stimulants listed above, or for those who develop significant depression or other side effects on stimulants, or for the treatment of ADHD symptoms in patients with tics or Tourette's disorder. Psychotherapy is appropriate patients also exhibit anxiety and/or depression.

There is a lack of scientific evidence to support the use of megavitamin therapy, herbal remedies, cognitive behavior modification, anti-motion-sickness medication, anti-candida-albicans medication, psychopharmaceuticals such as lithium, benzodiazepines, and selective serotonin re-uptake inhibitors, biofeedback, sensory (auditory) integration therapy, optometric vision training/Irlen lenses, chiropractic manipulation, or dietary interventions for the treatment of ADHD.

The American Academy of Pediatrics (2000) has the following statements regarding the diagnosis and evaluation of patients with ADHD:

• Regular screening of children for high lead levels does not aid in the diagnosis of ADHD.
• Current literature does not support the routine use of EEG in the diagnosis of ADHD.
• Available evidence does not support routine screening of thyroid function as part of the effort to diagnose ADHD.
• Neuroimaging studies should not be used as a screening or diagnostic tool for children with ADHD because they are associated with high rates of false-positives and false-negatives.
• Current data do not support the use of any available continuous performance tests in the diagnosis of ADHD.

Neuropsychological and psychological testing for purely educational reasons are not generally considered medically necessary. This testing is usually provided by school systems under applicable state and federal rules. Neuropsychological testing may be medically necessary in neurologically complicated cases of ADHD (e.g., post head trauma, seizures). Children with uncomplicated ADHD do not require neuropsychological or psychological testing.

Feifel (1996) stated that ADHD may affect up to 3% of the adult population. ADHD is not an acquired disorder of adulthood. Adults who were never diagnosed as having ADHD in childhood may present with many of the symptoms of the disorder. Inattention and distractibility, impulsivity, as well as hyperactivity are the classic hallmarks of ADHD, but adult patients often lack the full symptom complex, especially hyperactivity. Mood-associated symptoms (e.g., low frustration tolerance, irritability) are often present. In this regard, adults with ADHD usually have a difficult time with activities that require passive waiting. Adults with ADHD can be evaluated and successfully treated. Since the diagnosis is a clinical one, a comprehensive interview is the most important diagnostic procedure. A complete psychiatric evaluation with particular attention to the core symptoms of ADHD is essential for assessing ADHD in adults. Childhood history is also extremely important (Wender, 1998). 

Wender developed ADHD criteria, known as the Utah criteria, which reflect the distinct features of the disorder in adults (Wender, 1998). The diagnosis of ADHD in an adult requires a longstanding history of ADHD symptoms, dating back to at least age seven. In the absence of treatment, such symptoms should have been consistently present without remission. In addition, hyperactivity and poor concentration should be present in adulthood, along with two of the five additional symptoms: affective lability; hot temper; inability to complete tasks and disorganization; stress intolerance; and impulsivity.

The same medications used for children with ADHD are effective in adult patients. In a randomized controlled study (n = 146), Spencer et al (2005) concluded that robust doses of methylphenidate (average of 1.1mg/kg body weight/day) are effective in the treatment of adult ADHD. This is in agreement with the findings from a meta-analysis (Faraone et al, 2004) that the degree of efficacy of methylphenidate in treating ADHD adults is similar to what has been reported from meta-analyses of the child and adolescent literature. However, it should be noted that there is limited information regarding the long-term use of stimulants in adults (Kooij et al, 2004).

Kates (2005) noted that pharmacotherapies for patients with adult ADHD include stimulants and antidepressants; and medication can benefit up to 60 % of patients. In a randomized controlled study (n = 162), Wilens et al (2005) concluded that bupropion XL is an effective and well-tolerated non-stimulant treatment for adult ADHD. Adler et al (2005) stated that the results of an interim analysis (97 weeks) of an ongoing, open-label study (n = 384) support the long-term safety, effectiveness, and tolerability of another non-stimulant, atomoxetine, for the treatment of adult ADHD.

In a meta-analysis on the use of EEG biofeedback for the treatment of ADHD, Monastra and colleagues (2005) critically examined the empirical evidence, applying the efficacy guidelines jointly established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR). On the basis of these scientific principles, EEG biofeedback was deemed to be "probably efficacious" for the treatment of ADHD. Although significant clinical improvement was reported in about 75 % of the patients in each of the published research studies, additional randomized, controlled group studies are needed in order to provide a better estimate of the percentage of patients with ADHD who will demonstrate such gains in clinical practice.

Jensen and Kelly (2004) examined the effects of yoga on the attention and behavior of boys with ADHD. Subjects were randomly assigned to a 20-session yoga group (n = 11) or a control group (cooperative activities; n = 8). They were assessed pre- and post-intervention on the Conners' Parent and Teacher Rating Scales-Revised: Long (CPRS-R:L & CTRS-R:L), the Test of Variables of Attention (TOVA), and the Motion Logger Actigraph. Data were analyzed using one-way repeated measures analysis of variance (ANOVA). Significant improvements from pre-test to post-test were found for the yoga, but not for the control group on five subscales of the Conners' Parents Rating Scales (CPRS): Oppositional, Global Index Emotional Lability, Global Index Total, Global Index Restless/Impulsive and ADHD Index. Significant improvements from pre-test to post-test were found for the control group, but not the yoga group on three CPRS subscales: Hyperactivity, Anxious/Shy, and Social Problems. Both groups improved significantly on CPRS Perfectionism, DSM-IV Hyperactive/ Impulsive, and DSM-IV Total. For the yoga group, positive change from pre- to post-test on the Conners' Teacher Rating Scales (CTRS) was associated with the number of sessions attended on the DSM-IV Hyperactive-Impulsive subscale and with a trend on DSM-IV Inattentive subscale. Those in the yoga group who engaged in more home practice showed a significant improvement on TOVA Response Time Variability with a trend on the ADHD score, and greater improvements on the CTRS Global Emotional Lability subscale. Results from the Motion Logger Actigraph were inconclusive. The authors noted that although these data did not provide strong support for the use of yoga for ADHD, partly because the study was under-powered, they did suggest that yoga may have merit as a complementary treatment for boys with ADHD already stabilized on medication, particularly for its evening effect when medication effects are absent. they stated that yoga remains an investigational treatment, and this study supported further research into its possible uses for this population. The authors stated that these findings need to be replicated on larger groups with a more intensive supervised practice program.

Rickson (2006) compared the impact of instructional and improvisational music therapy approaches on the level of motor impulsivity displayed by adolescent boys (n = 13) who have ADHD. A combination of a multiple contrasting treatment and an experimental control group design was used. No statistical difference was found between the impact of the contrasting approaches as measured by a Synchronized Tapping Task (STT) and the parent and teacher versions of Conners' Rating Scales Restless-Impulsive (R-I) and Hyperactive-Impulsive (H-I) subscales. The author noted that while no firm conclusions can be drawn, there are indications that the instructional approach may have contributed to a reduction of impulsive and restless behaviors in the classroom. In addition, over the period of the study, both music therapy treatment groups significantly improved accuracy on the STT, and teachers reported a significant reduction in Conners' DSM-IV Total and Global Index subscale scores. The author concluded that these findings tentatively suggested that music therapy may contribute to a reduction in a range of ADHD symptoms in the classroom, and that increasing accuracy on the STT could be related to improvement in a range of developmental areas-not specifically motor impulsivity.