Coverage for care related to autism spectrum disorders (ASD) is determined according to the member’s individual or group customer benefits.

Pediatricians can conduct ASD screenings during the Development/Behavioral Assessments that are mandated in the Patient Protection and Affordable Care Act beginning at 9, 18, and 30 months using several diagnostic tools, including:

• PEDS (Parents’ Evaluation of Development Status)
• CHAT (Checklist for Autism in Toddlers)
• M-CHAT (Modified Checklist for Autism in Toddlers)

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

• Behavioral health evaluation (90801, 90802)(Refer to Medical Policy Bulletin V-15 for additional information on psychiatric care.)
• Genetic testing (Refer to Medical Policy Bulletin L-34 for specific guidelines on genetic testing.)
• Hearing assessment (92551-29557, 92585-92586)
• 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)
• Psychological testing (96101-96103), developmental testing (96110-96111, G0451), neurobehavioral status exam (96116), neuropsychological testing (96118-96120) and standardized cognitive performance testing (96125)(Refer to Medical Policy Bulletin V-15 for additional information on these services.)
• Psychotherapy
• Physical medicine, occupational therapy, and speech therapy services (For information on physical medicine, occupational therapy, and speech therapy services see Medical Policy Bulletins Y-1, Y-2, and V-16.)
• Vision assessment (99172, 99173)(Refer to Medical Policy Bulletin V-31 for additional information on vision assessment.) 

Services beyond traditional medical management include the following covered services for insured business, 2 to 9, 10 to 50, and 51+, whose coverage is impacted by the West Virginia ASD mandate, or in accordance with the member's benefit contract.

• Services provided for purposes of behavior modification and/or training (applied behavioral analysis):
  • therapeutic behavioral services (H2019),
  • community based wrap-around services (H2021),
  • service plan development (H0032), and
  • sensory integration (97533) Refer to Medical Policy Bulletin Y-2 for specific guidelines on sensory integration

The following services are generally not covered for ASD (this list applies to all Plan members, including those whose coverage is impacted by the West Virginia ASD mandate, effective January 1, 2012, as defined below). The preponderance of peer-reviewed clinical literature does not support coverage for these services.

• Animal or pet assisted therapy (A9270)
• Chelation therapy and detoxification for heavy metals (See Medical Policy Bulletin I-5 for specific guidelines on chelation therapy.)
• Craniosacral therapy (A9270)
• Fibroblast growth factor 2 (A9270)
• Hydrotherapy (See Medical Policy Bulletin Y-1 for guidelines on hydrotherapy and physical medicine.)
• Hyperbaric oxygen therapy (See Medical Policy Bulletin Z-3 for specific guidelines on hyperbaric oxygen.)
• Intravenous Immune Globulin (IVIG)(See Medical Policy Bulletins I-8 and I-14 for specific guidelines on IVIG.)
• Music, art and activity therapy (G0176)
• Naltrexone therapy (See Medical Policy Bulletin I-92 for specific guidelines on Naltrexone therapy.)
• Neurofeedback (A9270)
• Peripheral stem cell transplantation and umbilical cord stem cell transplantation (See Medical Policy Bulletins S-73 and S-143 for specific guidelines on peripheral stem cell transplantation and umbilical cord stem cell transplantation.)
• Secretin therapy (J2850)
• Social therapeutic group (H0046) and behavioral health day treatment (H2012)
• Testing for immunologic abnormalities (82784, 82785, 82787, 83516-83520, and 86602-86804)
• Vitamin: laboratory testing (78270, 78271, 78272, 82180, 82306, 82607, 82608, 82652, 82746, 82747, 84207, 84252, 84425, 84446, 84590, 84591, and 84597)
• Vitamins, nutritional supplements, or diet-oriented therapy (See Medical Policy Bulletin V-44 for specific guidelines on medical nutrition therapy.)

When any of the above mentioned services are not covered, all related services are also not covered (e.g., E/M services, laboratory tests, infusion services, drug administration, etc.).

NOTE:

Unless otherwise specified in the medical policies cross-referenced above, a participating, preferred, or network provider can bill the member for the denied services.

Autism Spectrum Disorders Coverage Mandate effective January 1, 2012

The West Virginia ASD mandate applies to insured groups of 25+, however, the Plan is applying the mandate to insured groups of 2 to 9, 10 to 50, and 51+.

While the WV ASD mandate requires coverage for diagnosis and treatment of ASD in individuals ages 18 months to eighteen years, the Plan will apply the mandate to individuals under age 18 months as well. Coverage will be provided for treatments that are medically necessary and ordered or prescribed by a certified behavioral analyst for an individual diagnosed with ASD, in accordance with a treatment plan developed by a certified behavioral analyst pursuant to a comprehensive evaluation or reevaluation of the individual, subject to review every six months.

Progress reports are required to be filed semi-annually. In order for treatment to continue, there must be objective evidence or a clinically supportable statement of expectation that:

• The individual’s condition is improving in response to treatment; and
• A maximum improvement is yet to be attained; and
• There is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

Coverage includes, but is not limited to, applied behavioral analysis provided or supervised by a certified behavioral analyst, provided, that the annual maximum benefit for treatment per individual, per year is not exceeded.

Refer to Medical Policy Bulletin Z-27 for information on Eligible Providers and Supervision Guidelines.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.

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.

Myers SM, Johnson CP, and the Council on Children With Disabilities Management of Children With Autism Spectrum Disorders. Pediatrics. 2007;120:1162-1182.

Johnson CP, Myers SM, and the Council on Children With Disabilities Identification and Evaluation of Children With Autism Spectrum Disorders. Pediatrics. 2007;120:1183-1215.

Carr JE. Autism spectrum disorders in early childhood: an overview for practicing physicians. Prim Care. 2007 Jun;34(2):343-59.

Rapin I. Autism: Definition, Neurobiology, Screening, Diagnosis. Pediatr Clin North Am. 2008 Oct;55(5):1129-1146.

Weber W. Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatr Clin North Am. 2007 Dec;54(6):983-1006.