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| Medical Policy: | V-37-031 |
| Topic: | Autism Spectrum Disorders |
| Section: | Visits |
| Effective Date: | April 2, 2018 |
| Issue Date: | August 6, 2018 |
| Last Reviewed: | July 2018 |
Autistic Spectrum Disorders (ASD) as defined in the most recent edition and as amended of the American Psychiatric Association is a group of developmental and neurobiological disorders( previously referred to as: atypical autism, Asperger’s disorder, childhood autism, childhood disintegrative disorder, early infantile autism, high-functioning autism, Kanner’s autism and pervasive developmental disorder not otherwise specified) currently characterized by atypical development in:
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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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Act 62 – 2008 (Autism Spectrum Disorders Coverage Mandate): Effective July 1, 2009. Act 62 applies to: Group contracts offered, issued or renewed on or after July 1, 2009 to fully insured-employers of 51 or more employees; and CHIP programs with respect to contracts executed on or after July 1, 2009.
- Act 62-2008 (Autism Spectrum Disorders Coverage Mandate) requires coverage for individuals who are under twenty-one (21) years of age for the diagnostic assessment and treatment of ASD.
- Treatment of ASD must be identified in a treatment plan and should include any medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care, including applied behavioral analysis, and therapeutic care that is:
- Prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner; or
- Provided by an autism service provider; or
- Provided by a person, entity or group that works under the direction of an autism service provider.
- The treatment plan must be developed by a physician or psychologist, following a comprehensive evaluation consistent with the most recent clinical report or recommendations of the American Academy of Pediatrics.
- The treatment plan may be reviewed once every six (6) months, subject to the Plan’s utilization review requirements, including case management, concurrent review and other managed care provisions; or
- A more or less frequent review can be agreed upon by the Plan and the physician or psychologist developing the treatment plan; and
- The provider is responsible for maintaining a copy of the autism assessment and treatment plan to be made available upon request.
- Coverage is subject to copayment, deductible and coinsurance provisions, as well as any other general exclusions or limitations set forth in the member’s contract.
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; or
- Behavioral assessment; or
- Adaptive behavior treatment; or
- Genetic testing; or
- Hearing assessment; or
- Medical assessment and evaluation (complete history and physical examination); or
- EEG; or neurological consult when in the presence of focal signs or clinical findings suggestive of a seizure disorder or a degenerative neurological condition; or
- Measurement of blood levels for lead or heavy metal exposure; or
- Pharmacotherapies; or
- Psychological testing; or
- Developmental testing; or
- Neurobehavioral status exam; or
- Neuropsychological testing; or
- Standardized cognitive performance testing; or
- Psychotherapy; or
- Physical medicine, occupational therapy, and speech therapy services; or
- Vision assessment.
Services beyond traditional medical management of ASD include the following covered services for groups, CHIP, and Adult Basic members whose coverage is impacted by the ASD mandate under Act 62; 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; or
- Community based wrap-around services; or
- Service plan development; or
- Sensory integration.
The following services are not covered for ASD (this list applies to all Plan members, including those whose coverage is impacted by the ASD mandate under Act 62-2008, defined below). The preponderance of peer-reviewed clinical literature does not support coverage for these services.
- Animal or pet assisted therapy; or
- Chelation therapy and detoxification for heavy metals; or
- Craniosacral therapy; or
- Fibroblast growth factor 2; or
- Hydrotherapy; or
- Hyperbaric oxygen therapy; or
- Intravenous Immune Globulin (IVIG); or
- Music, art and activity therapy; or
- Naltrexone therapy; or
- Neurofeedback; or
- Peripheral stem cell transplantation and umbilical cord stem cell transplantation; or
- Secretin therapy; or
- Social therapeutic group and behavioral health day treatment. These services are not a standard benefit under the member’s benefit contract; or
- Testing for immunologic abnormalities; or
- Vitamin: Laboratory testing; or
- Vitamins, nutritional supplements, or diet-oriented 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.).
Refer to medical policy I-5 Chelation Therapy/Chemical Endarterectomy for additional information. Refer to medical policy I-14 Immune Globulin Therapy for additional information. Refer to medical policy I-92 Naltrexone Extended Release Injection (Vivitrol®) for additional information. Refer to medical policy L-34 Genetic Testing for additional information. Refer to medical policy S-73 Bone Marrow Donor Search Charges for additional information. Refer to medical policy S-143 Donor Leukocyte Infusion for Hematologic Malignancies that Relapse after Allogeneic Stem Cell Transplant for additional information. Refer to medical policy Y-2 Occupational Therapy (OT) for additional information. Refer to medical policy V-31 Medical Care and Associated Services for additional information. Refer to medical policy V-15 Psychiatric Care Defined for additional information. Refer to medical policy V-44 Medical Nutrition Management Services (MNT) for additional information. Refer to medical policy Y-1 Physical Medicine for additional information. Refer to medical policy V-16 Speech Therapy for additional information. Refer to medical policy Z-3 Hyperbaric Oxygen (HBO) Therapy for additional information. Refer to medical policy Z-27 Eligible Providers and Supervision Guidelines for additional information. |
| Place of Service: Outpatient |
ASD are typically outpatient procedures which are only eligible for coverage as inpatient procedures in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
