Many Mountain State contracts exclude coverage for care related to certain conditions when the care extends beyond traditional medical management or when services are provided for environmental change.  This limitation applies to the following conditions:

• autistic disease of childhood (299.00-299.01, 299.80-299.81)
• hyperkinetic syndromes including attention deficit disorder with or without mention of hyperactivity (predominantly inattentive type) (314.00-314.01, 314.1-314.9)
• learning disabilities (315.00-315.09, 315.1-315.2, 315.31-315.39, 315.4-315.9)
• behavioral problems (312.00-312.23, 312.30-312.39, 312.4, 312.81-312.89, 312.9, 313.81, V40.0, V40.3, V40.9) or
• mental retardation (317, 318.0-318.2, 319)

Traditional medical management of these conditions may include the following common examples and is covered in accordance with the member’s benefit contract (this is not an all-inclusive list):

• Medical assessment and evaluation (complete history and physical examination)
• EEG (95812-95830), or neurological consult (99241-99255) when in the presence of focal signs or clinical findings suggestive of a seizure disorder or a degenerative neurological condition
• Measurement of blood levels for lead or heavy metal exposure (83015-83018, 83655)
• Pharmacotherapies (subject to the member’s specific benefits for drug coverage)
• Psychotherapy as appropriate, when the patient has a reasonable expectation of achieving sustainable measurable improvement in a reasonable and predictable period of time
• Physical medicine, occupational therapy, and speech therapy services as appropriate, when the patient has a reasonable expectation of achieving sustainable measurable improvement in a reasonable and predictable period of time

Mountain State contracts generally provide coverage for diagnostic and therapeutic services for medical conditions that lend themselves to improving with treatment (e.g., speech disorders), regardless of whether the patient also has any type of behavioral or developmental disorder.  This includes physical medicine, occupational therapy, and speech therapy services as appropriate, when the patient has a reasonable expectation of achieving sustainable measurable improvement in a reasonable and predictable period of time. 

Coverage for services related to some or all of these conditions is based on group customer benefits (i.e., some group customers may exclude coverage for services related to autistic disease of childhood, hyperkinetic syndromes including attention deficit disorder with or without hyperactivity (predominately inattentive type), learning disabilities, behavioral problems, and mental retardation).

NOTE:

(For additional information on psychotherapy see Medical Policy Bulletins V-15 and V-17. For information on physical medicine, occupational therapy, and speech therapy services see Medical Policy Bulletins Y-1, Y-2, and V-16).

The following services are generally not covered:

• Service that are primarily educational in nature (e.g., academic skills training, those for remedial education or those that may be delivered in a classroom-type setting)
• Educational testing (e.g., I.Q., mental ability, achievement and aptitude testing), except for specific evaluation purposes directly related to traditional medical treatment
• Services provided for purposes of behavior modification and/or training
• Services provided primarily for social or environmental change unrelated to medical treatment
• Developmental or cognitive therapies that are not restorative in nature or will not improve a level of function
• Services provided for which, based on medical standards, there is no established expectation of achieving sustainable measurable improvement in a reasonable and predictable period of time

NOTE:

A participating, preferred, or network provider can bill the member for the denied item or service.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Autism and Other Pervasive Developmental Disorders, American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues, Journal American Academy Child and Adolescent Psychiatry Volume 38, 12/1999

Practice Parameter: Screening and Diagnosis of Autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society, Neurology, Volume 55, No. 4, 08/2000

The Pediatrician’s Role in the Diagnosis and Management of Autistic Spectrum Disorder in Children, American Academy of Pediatrics, Volume 107, No. 5, 05/2001

Childhood and Adolescent Psychological Development, Pediatric Clinics of North America, Volume 50, No. 4, 08/2003