MEDICAL POLICY No R4

Transcription

1 *Note: This policy incorporates the previously separate policy Pervasive Developmental Disabilities # Summary of Changes Due to the Patient Protection and Affordable Care Act (PPACA), applied behavioral analysis for the treatment of autism spectrum disorder is now considered an essential health benefit and must be included in the definition of Habilitation Services as ordered by the State of Michigan effective January 1, 2014 for PPACA compliant health plans. Due to ongoing legislative changes, there will no longer be any annual visit limitations or annual dollar limitations applied to services for the treatment of Autism Spectrum Disorder. Please note the removal of the benefit limitations will take place as plans renew on or after January 1, See plan documents for applicable copayment and coinsurance that apply to various Treatments of Autism Spectrum Disorder categories. Due to differences in employer sponsored products, individual plan documents will govern in any situations in which this policy conflicts with the plan documents. Clarifications: Policy title changed from Autism Spectrum & Pervasive Developmental Disorders to Autism Spectrum Disorders. Deletions: Additions: Pg 1, Section I, A, eligibility criteria updated to read: This policy applies to individuals diagnosed with Autism Spectrum Disorder. Pg 2, Section I, Diagnosis and Evaluation, A, criteria updated to reflect an evaluation is required every three years for a child in ongoing treatment. Pg 2, Section I, Diagnosis and Evaluation, A, b, Autism Diagnostic Observation Schedule 2 (ADOS-2) added to list of Priority Health preferred diagnostic evaluation tools for autism. Pg 4, Section I, Exclusions, C, updated to reflect treatment coverage for all other developmental disorders including Social Communication Disorder, with the exception of medical management, are excluded from coverage. Pg 6, Section IV, Description, updated to reflect changes made in the newest revision of the DSM (DSM V). I. POLICY/CRITERIA Eligibility MEDICAL POLICY AUTISM SPECTRUM DISORDERS Effective Date: January 1, 2015 Review Dates: 12/10, 12/11, 8/12, 8/13, 12/13, 11/14 Date Of Origin: October 13, 2010 Status: Current A. This policy applies to individuals diagnosed with Autism Spectrum Disorder by a licensed physician or a licensed psychologist B. This policy applies to children and adolescents through age 18. Page 1 of 12

2 C. Applied Behavior Analysis (ABA) treatment services must be prior approved through Priority Health s Behavioral Health department. D. ABA and psychological treatment services for autism must be performed by a contracted provider who is supervised by a Board Certified Behavior Analyst (BCBA) or licensed psychologist so long as the services performed are commensurate with the psychologist s formal university training and supervised experience. Prior authorization is required for ABA and psychological treatment. E. For speech therapy treatment, physical therapy, and occupational therapy coverage is provided if performed by a contracted and licensed therapist who has met Priority Health s criteria for treatment of autism. Prior authorization for these therapies is not required. Diagnosis and Evaluation A. Initial evaluation for diagnostic clarification, including psychological and neuropsychological testing, is covered by the Plan when performed by a contracted licensed physician or psychologist. The Plan may request a diagnostic evaluation not more than once every three years. For a child in ongoing treatment, a new evaluation is required every three years. Use of diagnostic and screening tools with good reliability, sensitivity and specificity is required prior to approving treatment. Priority Health preferred diagnostic evaluation tools for autism: a. Autism Diagnostic Observation Scale (ADOS) b. Autism Diagnostic Observation Schedule-2 (ADOS-2) c. Autism Diagnostic Interview Revised (ADI-R) Validated screening tools include, but may not be limited to: d. Childhood Autism Rating Scale e. Australian Scale for Asperger s Syndrome f. Gilliam Autism Rating Scale-4 (GARS-4) g. Gilliam Asperger s Disorder Scale (GADS) h. Social Communication Questionnaire (SCQ) i. Social Responsiveness Scale (SRS) B. Referral to a contracted autism treatment program must be ordered by a licensed physician. Priority Health may request a second diagnostic opinion from either (a) an approved Centers of Excellence program or (b) a contracted, licensed PhD psychologist/neuropsychologist with specialized training in autism spectrum disorders prior to authorizing ABA autism treatment. Page 2 of 12

3 C. To determine the most appropriate level of treatment, the approved ABA Centers of Excellence program s evaluation and assessment should involve a multidisciplinary approach that includes: a. family interview and history b. developmental history c. use of a standardized parent completed checklist/behavior rating scale d. review of school records (if applicable) e. medical screening for co-morbid diagnoses f. structured behavioral observations D. Evaluation by the ABA Centers of Excellence program may result in a course of treatment that may vary in duration and length depending upon the individual treatment needs of the child. An Applied Behavior Analysis treatment plan must be supervised by a Board Certified Behavior Analyst (BCBA) who oversees the applied behavior analysis treatment and coordinates care with other medical professionals involved in the child s treatment as necessary. E. Referral to a contracted, licensed Speech Therapist for treatment of speech deficits as result of Autism must be ordered by a licensed physician. F. The Plan may request to the treatment program that an annual developmental evaluation be conducted to measure treatment progression. Treatment Coverage A. Coverage for treatment of Applied Behavior Analysis may include the following multidisciplinary components as dictated by the initial assessment and subsequent treatment plan: a. Physician b. Board Certified Behavior Analyst c. Psychologist (PhD) d. Psychologist (LLP) e. Social Worker (LMSW) f. Supervised Staff B. Approved outpatient ABA Centers of Excellence programs will be required to document progress in the treatment plan for consideration of continuing stay approval. Continuing stay criteria includes demonstrating measurable progress based on a treatment plan that specifically addresses clinical intervention in the following areas: a. Educational b. Psychosocial c. Behavioral d. Targeted symptom management Page 3 of 12

4 e. Skills training f. Parent training g. Care coordination with school and medical practitioners If the above clinical interventions do not result in measurable progress over a 6 month intervention period, then further treatment may be denied. Measurable progress includes demonstrated improvements in at least 2 of the following areas: Language Academic performance Adaptive behaviors Social behaviors C. Coverage for speech therapy treatment is covered when ordered by a licensed physician. See exclusion section of this policy for speech therapy treatments that are not approved for coverage of autism Exclusions A. Adults age 19 or older B. Services provided by family or household members C. Treatment coverage for all other developmental disorders including Social Communication Disorder with exception of medication management. Rationale: The Individuals with Disabilities Education Act (IDEA) of 1990 (20 U.S.C.A Sections 1400 et seq.) is federal legislation that assures all children with disabilities have available to them a free appropriate public education. A free appropriate public education encompasses special education and related services, including some therapy services that are provided at public expense. In Michigan, pursuant to this federal legislation, special education, intervention and related services are proved to children from birth to age 26, provided criteria are met to qualify for services. (see Section V of this policy for diagnostic code exclusions) D. Treatments that are not based in scientific evidence and unproven treatments are not covered by Priority Health. These treatments include, but are not limited to the following: a. Secretin therapy b. Dietary interventions c. Hormonal therapies d. Vitamin therapies e. Intravenous immunoglobulin therapy Page 4 of 12

5 f. Chelation therapy g. Facilitated communication h. Sensory Based Treatments i. Auditory Integration Therapy j. Relationship Development Intervention (RDI) k. Floor Time or Individual Difference Relationship (DIR) l. Non-biological complementary and alternative medicine treatments II. MEDICAL NECESSITY REVIEW A. EVALUATION & DIAGNOSTIC TESTING Required *Not Required Not Covered B. AUTISM TREATMENT SERVICES Applied Behavior Analysis (ABA), including ABA treatment in the home environment *Required Not Required Not Covered Mental Health Treatment for *Required Not Required Not Covered Speech Therapy Treatment for Required *Not Required Not Covered For Medicare, please see LCD (L30489) for coverage details For Individual products, please see plan documents. *NOTE: All services in A and B above for Priority Health Medicaid and Healthy Michigan Plan members are managed through Michigan s Department of Community Mental Health. Services in A and B above are not covered by the health plan for Priority Health Medicare members. Page 5 of 12

6 III. APPLICATION TO PRODUCTS Coverage is subject to member s specific benefits. Covered Autism Spectrum Disorder services are specified in your Schedule of Copayments and Deductibles under treatment for Autism Spectrum Disorder. HMO/EPO: This policy applies to insured HMO/EPO plans. POS: This policy applies to insured POS plans. PPO: This policy applies to insured PPO plans. Consult individual plan documents as state mandated benefits may apply. If there is a conflict between this policy and a plan document, the provisions of the plan document will govern. ASO: For self-funded plans, consult individual plan documents. If there is a conflict between this policy and a self-funded plan document, the provisions of the plan document will govern. INDIVIDUAL: For individual policies, consult the individual insurance policy. If there is a conflict between this medical policy and the individual insurance policy document, the provisions of the individual insurance policy will govern. MEDICARE: Coverage is determined by the Centers for Medicare and Medicaid Services (CMS); if a coverage determination has not been adopted by CMS, this policy applies. MEDICAID/HEALTHY MICHIGAN PLAN: For Medicaid/Healthy Michigan Plan members, this policy will apply. Coverage is based on medical necessity criteria being met and the appropriate code(s) from the coding section of this policy being included on the Michigan Medicaid Fee Schedule located at: If there is a discrepancy between this policy and the Michigan Medicaid Provider Manual located at: the Michigan Medicaid Provider Manual will govern. For Medical Supplies/DME/Prosthetics and Orthotics, please refer to the Michigan Medicaid Fee Schedule to verify coverage. MICHILD: For MICHILD members, this policy will apply unless MICHILD certificate of coverage limits or extends coverage. IV. DESCRIPTION (ASDs) are life-long neurological disabilities of unknown causes. The spectrum of autistic disorders includes previous DSM IV classifications of Autistic Disorder, Asperger Syndrome, Rett Disorder, Childhood Disintegrative Disorder and Pervasive Developmental Disorders Not Otherwise Specified (also known as Atypical Autism). The newest revision of the DSM (DSM V) combines these disorders into the broader category of autism spectrum disorders. Rett Disorder, if associated with ASD, is now additionally specified as a known genetic condition. Individuals with these disorders exhibt 1) deficits in social communication and interaction and 2) restricted, repetitive patterns of behavior, interests or activities. ASD diagnosis requires evidence of symptoms within both domains. Symptoms must be present in the early developmental period but may not become fully manifest until social demands exceed limited capacities and/or may be masked by learned strategies later in life. ASD may be diagnosed with other comorbid conditions such as ADHD, anxiety and language impairment. Recent prevalence data estimates that about 1 in 88 children have been identified with an autism spectrum disorder (ASD). ASDs are generally not curable and chronic Page 6 of 12

7 management is required. Although outcomes are variable and specific behavioral characteristics change over time, most children with ASDs remain with symptoms of autism as adults. V. CODING INFORMATION Note: Services for Priority Medicaid and Healthy Michigan Plan Members are paid through Michigan s Department of Community Mental Health. ICD-9 Codes (for dates of service on or before September 30, 2015): The following services are covered under this policy when billed with the following dx: Autistic disorder, current or active state Other specified pervasive developmental disorders, current or active state (Asperger s disorder, Rhett s disorder) Unspecified pervasive developmental disorder, current or active state ICD-10 Codes that apply to this policy (for dates of service on or after October 1, 2015): The following services are covered under this policy when billed with the following dx: F84.0 Autistic disorder F84.5 Asperger's syndrome F84.8 Other pervasive developmental disorders F84.9 Pervasive developmental disorder, unspecified BEHAVIORAL HEALTH SERVICES Prior authorization required Mental Health Treatment Revenue Codes (facility only) 0914 Individual therapy Mental Health Treatment CPT/HCPCS Codes Prior authorization required when billed with primary autism spectrum disorder diagnoses Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; ABA TREATMENT SERVICES in center, office, or home prior authorization required Page 7 of 12

8 Revenue Codes (facility only) 0914 Individual therapy CPT/HCPCS Codes H0031 Mental health assessment, by nonphysician H0032 Mental health service plan development by nonphysician H2019 Therapeutic behavioral services, per 15 minutes SPEECH THERAPY - no prior authorization required Revenue Codes (facility only) Speech Therapy-Language Pathology CPT/HCPCS Codes Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Behavioral and qualitative analysis of voice and resonance S9152 Speech therapy, re-evaluation Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals PHYSICAL & OCUUPATIONAL THERAPY - no prior authorization required Revenue Codes (facility only) Physical Therapy Occupational Therapy CPT/HCPCS Codes Physical therapy evaluation Physical therapy re-evaluation Occupational therapy evaluation Occupational therapy re-evaluation Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Page 8 of 12

9 97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes BEHAVIORAL HEALTH EVALUATION - prior authorization is required for Medicaid/Healthy Michigan Plan members for these services regardless of diagnosis. These services are NOT dependent on diagnoses above and are not subject to the autism benefit: Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication BEHAVIORAL HEALTH TESTING - no prior authorization required Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report Developmental screening, with interpretation and report, per standardized instrument form (Not payable to facility providers) Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified Page 9 of 12

10 health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report ICD-9 Non Covered Codes including but not limited to: (for dates of service on or before September 30, 2015): Autistic disorder, residual state Childhood disintegrative disorder, current or active state Childhood disintegrative disorder, residual state Other specified pervasive developmental disorder, residual state Unspecified pervasive developmental disorder, residual state See also: Policy Rehabilitative Medicine Services Policy Speech Therapy Policy Neuropsychological and Psychological Testing CPT/HCPCS Codes Services not covered with the diagnoses above include but are not limited to: Behavioral Therapy Speech Therapy Occupational Therapy Physical Therapy Services not covered regardless of diagnosis: 0359T Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report 0360T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-toface with the patient 0361T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient (List separately in addition to code for primary service) 0362T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient 0363T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the Page 10 of 12

11 0364T 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient (List separately in addition to code for Adaptive behavior treatment by protocol, administered by technician, face-toface with one patient; first 30 minutes of technician time Adaptive behavior treatment by protocol, administered by technician, face-toface with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time (List separately in addition to code for primary procedure Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure) Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in addition to code for primary procedure) VI. REFERENCES Ben-Itzchak E, Zachor DA. The effects of intellectual functioning and autism severity on outcome of early beavhavioral intervention for children with autism. Res Dev Disabil. 2007;28(3): Centers for Disease Control and Prevention. Community Report from the Autism and Developmental Disabilities Monitoring (ADDM) Network. Report.pdf. Eikeseth S, Smith T, Jahr E, Eldevik S. Intensive behavioral treatment at school for 4-7-year-old children with autism. A 1-year comparison controlled study. Behav Modif. 2002;26(1): Page 11 of 12

12 Eikeseth S, Smith T, Jahr E, Eldevik S. Outcome for children with autism who began intensive behavioral treatment between ages 4 and 7: a comparison controlled study. Behav Modif. 2007;31(3): Howard JS, Sparkman CR, Cohen HG, et al. A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Res Dev Disabil. 2005;26(4): Itzchak, B. E, Lahat E, Burgin R, Zachor AD. Cognitive, behavior and intervention outcome in young children with autism. Res Dev Disabil. 2008; 29(5): Myers, S. M. Management of children with autism spectrum disorders. American Academy of Pediatrics. 2007; 120(5): Reichow B, Wolery M. Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA young autism project model. J Autism Dev Disord. 2009; 39(1): 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. 2008; PMID: AMA CPT Copyright Statement: All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association. This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered. Priority Health s medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Priority Health reserves the right to review and update its medical policies at its discretion. Priority Health s medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. The name Priority Health and the term plan mean Priority Health, Priority Health Managed Benefits, Inc., Priority Health Insurance Company and Priority Health Government Programs, Inc. Page 12 of 12