Aetna Adds PANS/PANDAS to Medical Policy

We’re encouraged to share that Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) / Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) is now officially listed in Aetna’s medical policy—an important milestone for recognition and access to care.

Why Aetna’s Recognition of PANS/PANDAS Matters

  • The policy recognizes that symptom onset typically occurs between ages 3 and puberty
  • This inclusion may signal progress, and we anticipate more insurers may follow suit
  • Clear diagnostic and documentation criteria are outlined for medical necessity

What Aetna’s PANS/PANDAS Medial Policy Includes

Therapy may be considered medically necessary when the following criteria are met:

Diagnostic Criteria

The child meets PANS Research Consortium diagnostic criteria, including:

  • A sudden, dramatic onset (less than one month) of obsessive compulsive disorder (OCD) or severely restricted food intake
  • At least two additional neuropsychiatric symptoms with acute onset, such as:
    • Anxiety
    • Emotional lability and/or depression
    • Irritability, aggression, or severe oppositional behaviors
    • Developmental or behavioral regression
    • Decline in school performance (including ADHD like symptoms, memory, or cognitive changes)
    • Sensory or motor abnormalities
    • Physical symptoms such as sleep disturbances, bedwetting, or urinary frequency

Additional Requirements for Medical Necessity

  • Symptom onset between 3 years of age and puberty
  • Other potential causes of symptoms have been ruled out
  • The child has tried and not responded to systemic corticosteroids
  • Submission of a baseline objective symptom assessment, such as:
    • Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
    • Clinical Global Impression of Severity (CGIS)
    • Parent-Rated PANS Scale

Continuation of Therapy Criteria

Ongoing treatment may be considered medically necessary when there is documented objective clinical improvement, measured using the same standardized assessment tools.

A Step Toward Access to PANS/PANDAS Care

This is a meaningful step toward greater awareness, validation, and access to care for children and families affected by PANS/PANDAS. We’ll continue watching for updates as insurance coverage evolves.

For full policy details, Visit Aetna’s medical policy page: https://www.aetna.com/cpb/medical/data/200_299/0206.html