| Highmark Commercial Medical Policy - Pennsylvania |
| 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.
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):
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.
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.
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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