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Date Printed: December 16, 2017: 09:00 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-97000-08

Original Effective Date: 04/01/09

Reviewed: 12/06/12

Revised: 12/01/16

Subject: Treatment of Autism Spectrum Disorders

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Update  
           

DESCRIPTION:

Autism is a common condition in a group of developmental disorders known as the Autism Spectrum Disorders (ASDs) or Pervasive Developmental Disorders (PDD). The autism spectrum symptomatology is characterized by impaired social interaction, problems with verbal and nonverbal communication, and unusual, repetitive, or severely limited activities and interests. Other ASDs include Asperger syndrome, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS).

Asperger syndrome is a milder form of ASD, while Rett syndrome has been diagnosed almost exclusively in females, and is far less common. Childhood disintegrative disorder is a rare form of Autism. The Centers for Disease Control & Prevention (CDC) published new data on March 30, 2012, showing that 1 in 88 children, or 1.13 percent of U.S. children, have been diagnosed with autism spectrum disorder (ASD). This represents a 23 percent increase in the past two years.

The National Institute of Mental Heath indicates that ASDs are reliably diagnosed by the age of 3 and can be diagnosed as early as 18 months of age. Parents are usually the first to recognize that the child’s unusual behavior or development. All children should have routine developmental exams by their pediatrician during their well child visits. Further testing may be initiated if there is concern on the part of the doctor or parents. This is particularly true whenever a child fails to meet any of the following language milestones:

The American Academy of Pediatrics recommends routine ASD screening at 18 and 24 months, and surveillance at every visit.

Screening during a well child exam may include the Checklist for Autism in Toddlers (CHAT), The Screening Tool for Autism in Two-Year-Olds (STAT), and the Social Communication Questionnaire (SCQ), as well as other screening methods. In July 2012, The AAP outlined the Modified Checklist for Autism in Toddlers (mCHAT) for toddlers 16-48 months, as part of the AAP Bright Futures prevention and health promotion program. The screening methods do not provide a diagnosis, but serve as an assessment for the need for further referral or testing. The appearance of any warning sign of ASDs should be evaluated by a professional specializing in the diagnosis and treatment of these disorders. A team of specialists may be required to provide the comprehensive diagnosis and treatment of ASDs or PDD, which includes a developmental pediatrician, psychologist, neuropsychologist, psychiatrist, neurologist, and other medical specialists.

Individuals with ASDs or PDD may display a wide range of behavioral symptoms, which can range from mild to severe. A wide variety of other symptoms can accompany ASDs involving sensory perception, mental impairment, and speech, language and communication impairment.

There is no single treatment for autism spectrum disorders. It is reported that early diagnosis and treatment results in improved outcomes for those diagnosed with autism spectrum disorders. The following therapies have been proposed to minimize the symptoms of autism:

Applied Behavioral Analysis (ABA) is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior. ABA services include the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. Methods that use the principle of positive reinforcement to strengthen a behavior by arranging for it to be followed by something of value have been used to develop a wide range of skills in learners’ with and without disabilities. Almost all of the literature on controlled trials of efficacy is on children below the age of 10.

Board certified behavior analysts are credentialed by the Behavioral Analyst Certification Board. Typically, they are unlicensed by many states. They use positive reinforcement and other principles to build communication, play, social, academic, self-care, work, and community living skills, and to reduce problem behaviors in learners with autism. ABA techniques involve instruction that is directed by adults in highly structured fashion, while others make use of the learners’ natural interests and follow the individual’s initiations. ABA may also teach skills in the context of ongoing activities. All skills are broken down into small steps or components, and learners are provided many repeated opportunities to learn and practice skills in a variety of settings, with abundant positive reinforcement. The goals of intervention as well as the specific types of instructions and reinforcers used can be customized to the strengths and needs of the individual learner. Performance is measured continuously by direct observation, and intervention is modified if the data show that the learner is not making satisfactory progress. Regardless of the age of the learner with autism, the goal of ABA intervention is to enable the ability to function as independently and successfully as possible in a variety of environments.

POSITION STATEMENT:

NOTE: Refer to member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusions, or criteria applicable to Autism services.

Children with autism often exhibit clinical and physical findings which represent comorbidities associated with the condition.

Medical comorbidities associated with autism spectrum disorder include:

• Seizure disorders

• Landau-Kleffner syndrome (acquired aphasia with epilepsy)

• Gastrointestinal problems (usually diarrhea and/or constipation)

• Tuberous sclerosis

• Insomnia

• Hearing impairment

• Vision impairment

• Motor impairments: including hypotonia, apraxia, coordination impairment, toe walking, gross motor delay

• Speech, language and non-verbal communications impairment

Physical therapy commonly focuses on development of strength, coordination, movement and improvement in gross motor skills such as lifting, reaching and running.

Occupational therapy commonly focuses on improving fine motor skills involving manipulation of the hands, such as the pincer, pronate and supinate grasps, and the dynamic tripod.

Speech therapy focuses on producing gains in speech, language and non-verbal communication skills.

Physical Therapy, Occupational Therapy and Speech Therapy, when rendered for the treatment of the co-morbidities of Autism Spectrum Disorders, meet the definition of medical necessity when ALL the following criteria are met:

• Therapy services are rendered in accordance with the treatment plan as prescribed by the treating physician and updated no less than every six (6) months

• The therapy treatment plan contains the diagnosis, the proposed treatment type, frequency, and duration of the treatment with the outcomes stated as goals

• The treatment plan includes the frequency of update to the treatment plan and the treating physician signature

• The therapy rendered is considered the standard of care for the co-morbid condition diagnosed by the treating physician.

ALL of the following services are considered experimental or investigational in the treatment of Autism Spectrum Disorders, as there is a lack of scientific evidence to draw conclusions as to the safety, efficacy, or effects on health outcomes for the treatment of Autism Spectrum Disorders:

BILLING/CODING INFORMATION:

Refer to section entitled Position Statement

REIMBURSEMENT INFORMATION:

NOTE: Refer to member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to Autism services.

PROGRAM EXCEPTIONS:

State Account Organization (SAO): Follow SAO guidelines.

Federal Employee Program (FEP): Follow FEP guidelines.

Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

Coverage mandated by the state of Florida: refer to member’s/subscriber’s contract benefits.

Coverage for speech therapy, occupational therapy, physical therapy, and applied behavior analysis is mandated by Florida statute for some contracts.

Florida Statute 627.6686 [Coverage for individuals with autism spectrum disorder required; exception] and Florida Statute 641.31098 [Coverage for individuals with developmental disabilities]:

A health maintenance contract shall provide coverage to an eligible individual for treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis.

When the mandate applies:

Children must be under 18 years of age, or still in high school, and have been diagnosed as having autism spectrum disorder at 8 years of age or younger, OR

Children must be under 18 years of age, or still in high school, and have been diagnosed as having Down syndrome.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Auditory Integration Training (AIT), 01-92502-13
Cognitive Rehabilitation, 01-97000-04

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, 05-82000-33

Hippotherapy, 01-97000-00

Hyperbaric Oxygen Therapy, 01-99180-01

Immune Globulin Therapy, 09-J0000-06

Physical Therapy and Occupational Therapy, 01-97000-01

Sensory Integration Therapy, 01-97000-03

Speech Therapy, 01-92506-01

OTHER:

None applicable.

REFERENCES:

  1. Agency for Healthcare Quality (AHRQ). Guideline Summary NGC-7513: Occupational therapy practice guidelines for children and adolescents with autism. American Occupational Therapy Association (AOTA).
  2. American Academy of Child and Adolescent Psychiatry. Practice Parameters For The Assessment And Treatment Of Children, Adolescents, And Adults With Autism And Other Pervasive Developmental Disorders. 1999.
  3. American Academy of Pediatrics Clinical Report: Identification and Evaluation of Children With Autism Spectrum Disorders. PEDIATRICS Volume 120, Number 5, November 2007.
  4. American Academy of Pediatrics Committee on Children With Disabilities. The Pediatrician’s Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children. Pediatrics Vol. 107 No. 5 May 2001, pp. 1221-1226.
  5. American Academy of Pediatrics Committee on Children With Disabilities Technical Report: The Pediatrician’s Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children. Pediatrics 2001 107: e85.
  6. American Academy of Pediatrics Committee on Children With Disabilities. Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. PEDIATRICS Vol. 118 No. 1 July 2006, pp. 405-420.
  7. American Academy of Pediatrics. Prevalence of Autism Disorders. March 29, 2012. Accessed at: http://www.aap.org/ on 10/30/12.
  8. American Academy of Pediatrics. The New AAP Autism Screening Guidelines. July 19, 2012. Accessed at http://www.aap.org on 10/30/12.
  9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (Fourth Edition).
  10. Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Special Report: Early Intensive Behavioral Intervention Based on Applied behavior Analysis among Children with Autism Spectrum Disorders. Volume 23, Number 9. February 2009, updated 2010. (Accessed 10/15/12).
  11. American Society of Neurophysiological Monitoring. Isley MR, Edmonds HL Jr, Stecker M, American Society of Neurophysiological Monitoring. Guidelines for intraoperative neuromonitoring using raw (analog or digital waveforms) and quantitative electroencephalography: a position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2009 Dec;23(6):369-90.
  12. American Speech-Language-Hearing Association. Roles and Responsibilities of Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span. Ad Hoc Committee on Autism Spectrum Disorders. 2006 (Accessed 10/15/12).
  13. Barbaresi WJ, Katusic SK, Voigt RG. Autism: A Review of the State of the Science for Pediatric Primary Health Care Clinicians. Arch Pediatr Adolesc Med. 2006; 160: 1167-1175.
  14. Carbone P, Farley M, Davis T. Primary Care for Children with Autism. American Family Physician. February 15, 2010 Volume 81, Number 4.
  15. Case-Smith J, Arbesman M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapy. American Journal of Occupational Therapy, 62, 416–429.
  16. Chris Plauché Johnson, Scott M. Myers, and the Council on Children With Disabilities. Identification and Evaluation of Children With Autism Spectrum Disorders. Pediatrics 2007 120: 1183-1215. ClinicalTrials.gov. NCT00374764. Comparison of Applied Behavioral Analysis (ABA) Versus ABA and Risperidone. Washington University School of Medicine. Last updated 02/15/07.
  17. ClinicalTrials.gov. NCT00374764. Comparison of Applied Behavioral Analysis (ABA) Versus ABA and Risperidone. Washington University School of Medicine. Last updated 02/15/07.
  18. Cohen H, Amerine-Dickens M, Smith T. Early intensive behavioral treatment: replication of the UCLA model in a community setting. J Dev Behav Pediatr. 2006 Apr; 27(2 Suppl): S145-55.
  19. Dawson G, et al. Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model. Pediatrics 2010;125;e17.
  20. ECRI Institute: Evidence Report: Comprehensive Educational and Behavioral Interventions for Autism Spectrum Disorders (early online final draft publication, uncopyedited) Plymouth Meeting, PA: ECRI. 02/09/09.
  21. ECRI Institute Evidence Report: Comprehensive Educational and Behavioral Interventions for Autism Spectrum Disorders. October 2011, Issue No. 189.
  22. ECRI Institute: Hotline Report: Applied Behavioral Analysis for Pervasive Developmental Disorders. Plymouth Meeting, PA: ECRI. 01/22/08.
  23. ECRI Institute: Hotline Report: Comprehensive treatment Programs for Pervasive Developmental Disorders. Plymouth Meeting, PA: ECRI. Updated 07/10/08.
  24. Filipek PA, et al, Practice Parameter: Screening and Diagnosis of Autism – Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society, accessed at: neurology.org 01/19/11. (Accessed 10/15/12).
  25. Florida Statute 393.063 Public Health, Developmental Disabilities, exception accessed at http://www.flsenate.gov/Laws/Statutes on 08/25/11.
  26. Florida Statute 627.6686, Coverage for individuals with autism spectrum disorder required; exception. Accessed at http://www.flsenate.gov/.
  27. Florida Statute 641.31098, Coverage for individuals with developmental disabilities. Accessed at http://www.flsenate.gov/.
  28. Hernandez P, Ikkanda Z. Applied behavior analysis Behavior management of children with autism spectrum disorders in dental environments. The Journal of the American Dental Association 2011;142(3):281-287.
  29. Makrygianni MK. A meta-analytic review of the effectiveness of behavioural early intervention programs for children with Autistic Spectrum Disorders. Research in Autism Spectrum Disorders 4 (2010) 577–593.
  30. McPheeters ML, et al. A Systematic Review of Medical Treatments for Children With Autism Spectrum. Pediatrics 2011;127;e1312
  31. Myers SM, Johnson CP. Management of Children With Autism Spectrum Disorders. American Academy of Pediatrics Council on Children With Disabilities. Guidance for the Clinician in Rendering Pediatric Care. PEDIATRICS Volume 120, Number 5, November 2007.National Institute of Mental Health. Autism Spectrum Disorders (Pervasive Developmental Disorders). Last updated April 3, 2008. Accessed 01/30/09.
  32. National Institute of Neurological Disorders and Stroke (NINDS). National Institutes of Health. Pervasive Developmental Disorders. Accessed on 01/29/09.
  33. National Institute of Neurological Disorders and Stroke (NINDS). National Institutes of Health. Asperger Syndrome Information Page. Last updated October 17, 2008. Accessed on 01/29/09.
  34. Nuwer M. Assessment of Digital EEG, Quantitative EEG and EEG Brain Mapping: Report of the American Academy of Neurology and the American Clinical Neurophysiology Society. Neurology 1997;49:277-292.
  35. Ospina MB, Krebs Seida J, Clark B, Karkhaneh M, Hartling L, et al. (2008) Behavioural and Developmental Interventions for Autism Spectrum Disorder: A Clinical Systematic Review. PloS ONE 3(11): e3755.
  36. Sallows GO, Graupner TD. Intensive behavioral treatment for children with autism: four-year outcome and predictors. Am J Ment Retard. 2005 Nov; 110(6): 417-38.
  37. Scott M. Myers, Chris Plauché Johnson the Council on Children With Disabilities Management of Children With Autism Spectrum Disorders. Pediatrics. 2007 120: 1162-1182.
  38. Spreckley M, Boyd R. Efficacy of Applied Behavioral Intervention in Preschool Children with Autism for Improving Cognitive, Language, and Adaptive Behavior: A Systematic Review and Meta-analysis. The Journal of Pediatrics March 2009. (Accessed 10/15/12)
  39. Virués-Ortega J. Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression and dose–response meta-analysis of multiple outcomes. Clinical Psychology Review 30 (2010) 387–399.
  40. Warren Z, McPheeters ML, Sathe N, Foss-Feig JH, Glasser A, Veenstra-VanderWeele J. A Systematic Review of Early Intensive Intervention for Autism Spectrum Disorders. Pediatrics Vol. 127 No. 5 May 1, 2011.
  41. Zwaigenbaum et al. Clinical Assessment and Management of Toddlers With Suspected Autism Spectrum Disorder: Insights From Studies of High-Risk Infants. Pediatrics. 2009;123:1383-1391.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/06/12.

GUIDELINE UPDATE INFORMATION:

04/01/09

New Medical Coverage Guideline.

09/15/09

Update exception statement.

04/15/10

Annual review; no change in position statement. References updated.

10/15/10

Revision; related ICD-10 codes added.

04/15/11

Annual review; position statement maintained and references updated.

12/15/11

Unscheduled review. Revised description section and position statement (added coverage criteria for physical therapy, occupational therapy and speech therapy for treatment of comorbidities of ASD,) updated references and reformatted guideline.

01/15/13

Scheduled review. Revised description and position statement (added E/I statement for QEEG). Updated references and reformatted guideline.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

07/15/16

Revision: Updated Program Exceptions section and references.

10/01/16

Revision: Billing/Coding Information section updated.

12/01016

Program Exceptions section revised.

Date Printed: December 16, 2017: 09:00 PM