CLINICAL CRITERIA FOR UM DECISIONS Autism Related Services

Transcription

1 Overview This medical policy is used to review and make benefit and/or medical-necessity decisions for Autism Related Services, including Developmental Therapy Services and Applied Behavioral Analysis (ABA) service requests for members with the diagnosis of Autism Spectrum Disorder (ASD). At an initial evaluation, target symptoms are identified. A treatment plan is developed that identifies the core deficits and aberrant behaviors, and includes designated interventions intended to address these deficits and behaviors and achieve individualized goals. Treatment plans are reviewed for medical necessity every six months to allow re-assessment and to document progress in improving the gap between member s core deficits, aberrant behaviors and skills acquired since therapy began. Coverage Guidelines Capital Health Plan may authorize ASD-related services only if all of the following criteria are met: 1. The Member has the benefit for ASD-related services,, 2. The member has a diagnosis of Autism Spectrum Disorder (ASD) from a clinician who is qualified to make such a diagnosis, as directed by the controlling state mandate. Such clinicians are usually a: neurologist, developmental pediatrician, pediatrician, psychiatrist, licensed clinical psychologist, or medical doctor experienced in the diagnosis of ASD. 3. Diagnostic evaluation with order / treatment recommendation for treatment includes: developmental and medical history, behavioral and cognitive evaluation, medical co-morbidity, neurological evaluation, autism specific assessments, and other information that may be required per state mandate. 4. Member is within the age range specified in the applicable health plan s member service plan description or in the state mandate for treatment. 5. The ABA services recommended do not duplicate or replicate services received in a member s primary academic educational setting, or are available within an Individualized Education Plan (IEP) or Individualized Service Plan (ISP). 6. There is a reasonable expectation that a member is able to, or demonstrates the capacity to, learn and develop generalized skills to assist in his or her independence and functional improvements. Generalization refers to the transfer of what is learned in one setting or situation to another setting or situation without explicit teaching or programming in the second transfer setting. In Applied Behavior Analysis, when we talk about generalization, we are often talking about teaching skills in one setting or situation and having the person start using those skills in another setting or situation. For example, if a child learns to tie her shoes with her mother at home, she will be able to tie her shoes when at school in the presence of her teacher or on her own. Clinical Criteria 1

2 7. The recommended ABA treatment is directed toward goals focused on ASD core deficits 8. Treatment is provided at the least restrictive and most clinically appropriate environment to safely, effectively and efficiently deliver care. Core skill deficits can be taught in a variety of settings but to the extent that they are done in naturally occurring settings for the child, it will increase the probability of their use. 9. Treatment intensity does not exceed the member s functional ability to participate. 10. Treatment is clinically appropriate and designed to meet the individualized needs of the member with regard to type, frequency, intensity, extent, site and duration of services. 11. On concurrent review, the current ABA treatment demonstrates significant improvement on treatment plan goals: a. Significant improvement is: mastery of a minimum of 50 percent of stated goals and/or objectives found in the submitted treatment plan. This is demonstrated through continuous process of data collection, including documented generalization of skills developed through goals across people, settings and environments. b. Evidence to show member progress and skills acquired since therapy began may include appropriate assessments or tests as follow-up measures of developmental/ behavioral progress or response to therapy. c. For members who do not master 50 percent of stated goals and objectives, the treatment plan should clearly address the barriers to treatment success. Testing may be requested to clarify lack of treatment response. If on subsequent reviews the member does not demonstrate significant improvement or progress mastering goals and objectives, continuation of coverage of ABA services may be denied. 12. Treatment is required for reasons other than the convenience of the patient, parents/caregiver/ guardian, or physician or other health care provider. 13. Treatment is not a substitute for non-treatment services addressing environmental factors, nor primarily for custodial or respite care. 14. ABA services are provided by a Board Certified Behavior Analyst (BCBA) or line therapist supervised by a BCBA. 15. A comprehensive medical record is submitted by the ABA provider documenting the course of ABA treatment that includes all of the following documentation: a. Initial assessment evaluation b. Individualized treatment plan with measurable goals and objectives that clearly addresses the target behaviors and functional skills of the member s core deficits of ASD, formulated based on current assessments with reasonable expectations of mastery within a six-month period. The treatment plan should document these areas: Clinical Criteria 2

3 i. Behavior; for example, reduction of problem behaviors such as operant ruminating/vomiting, tantrum behavior, aggression, or self-injurious behavior ii. Social; for example, engaging in social play, engaging in appropriate eye contact, demonstrating setting-specific behaviors iii. Communication; targets related to receptive and expressive communication and social language iv. Collected data, including additional testing such as ADOS (Autism Diagnostic Observation Schedule), ABLLS, VB-MAPP, Essential for Living or other developmentally or functionally appropriate assessments, celeration charts, graphs, progress notes that link to interventions of specific treatment plan goals/objectives v. Documentation of treatment participants and staff, procedures and setting vi. Clinical documentation that the ABA therapy is focused on active symptoms of ASD that inhibit daily functioning and that gains made through treatment close the current gap with the member s functioning level and same age peers vii. Parent/Guardian participation in 80 percent of scheduled parent training sessions, which demonstrates learning, applying and generalizing ABA techniques, and demonstration of accuracy of learned skills for any six month authorization period viii. Psychological evaluation within a 45-day period prior to the initial service request. Appropriate assessments or tests may be requested dependent on clinical information obtained during the course of ABA treatment. ix. Transition and aftercare planning. Capital Health Plan will review requests for ABA treatment benefit coverage based upon clinical information submitted by the provider. Clinical Information includes submission of the Initial Treatment Plan, accompanied by the Diagnostic Evaluation that specifies a diagnosis of ASD, current psychological testing scores, and any additional documentation of the member s condition (i.e., Early Intervention Services, IEP, pertinent medical records). Approved hours will be based on the following four tracts: a. Developmental b. Behavioral c. Functional d. Non-Acute All tracts offer two levels of care: a. Developmental i. Acute ii. Sub-acute b. Behavioral i. Acute ii. Sub-acute c. Functional i. Acute ii. Sub-acute Clinical Criteria 3

4 d. Non-Acute i. Developmental/Functional ii. Behavioral Autism Tracts Occupational Speech Physical Behavioral Therapy Therapy (OT) Therapy (ST) Therapy (PT) Developmental Acute 2x/week 2x/week 2x/week Up to 4 hours / week Developmental Sub-Acute 4x/week (any combination) Up to 4 hours / month Behavioral Acute 2x/week 2x/week 2x/week Up to 5 hours / week Behavioral Sub-Acute 4x/week (any combination) Up to 5 hours / month Functional Acute 2x/week 2x/week 2x/week Up to 5 hours / week Functional Sub-Acute 4x/week (any combination) Up to 5 hours / month Non-Acute Dev/Functional 4x/week (any combination) Up to 2 hours / month Non-Acute Behavioral 4x/week (any combination) Up to 2 hours / month Supervision/program modification/data analysis/program updates Up to 5 hours / month This approach allows the physician and therapist to identify an appropriate, effective amount of services to address developmental, behavioral, and/or Functional priorities while still addressing all issues, if necessary. The medical literature clearly supports ABA hours to be phased out and replaced by school attendance and group social activities as the child ages. Major improvements are generally recorded after two years of intensive ABA therapy. Initial intervention at a very young age is necessary for maximal benefit from ABA treatment. Additional hours may be requested based on the seriousness of the target behaviors and the extent of core deficits, supported by accepted research literature. a. Developmental Tract: Young toddlers and children newly diagnosed would often be served under this tract. These clients require more intensive developmental therapies. Children are likely difficult to engage, have little sense of reciprocity, poor self regulation and sustained attention affecting skill acquisition and learning. i. Acute developmental therapy services (as needed according to benefit package): 2 visits weekly of OT (30 minute sessions) 2 visits weekly of ST (30 minute sessions) 2 visits weekly of PT (30 minute sessions) Behavioral therapy (children 2-6 yrs) up to 4 hours per week over the course of 12 months ii. Sub-Acute developmental Services: 4 visits of developmental therapy weekly (30 minute sessions, any combination of OT/PT and/or ST) Behavioral therapy up to 4 hours per month over the course of one year. Clinical Criteria 4

5 b. Behavioral Tract: Typically provided to children with ASD for whom behavior is the primary component affecting function and skill acquisition. This level is not limited to any particular age. Developmental concerns may limit skill acquisition however; behavior concerns are affecting participation and learning. i. Acute behavioral services (as needed according to benefit package): 2 visits weekly of OT (30 minute sessions) 2 visits weekly of ST (30 minute sessions) 2 visits weekly of PT (30 minute sessions) Behavioral therapy up to 5 hours per week, including a one hour session per week for family/client centered training from BCBA over the course of one year. ii. Sub-Acute behavioral services: 4 visits (30 min) weekly of developmental therapy (combination of OT/PT and/or ST) Behavioral therapy up to 5 hours per month over the course of one year. c. Functional Tract: Functional skills are skills you teach to the child that are intended to be practical, useful, and helpful in a variety of settings. Children with autism may need to be specifically taught functional skills that other children readily learn from their environment. Functional skills should be age appropriate goals that are relevant to the people in the child's life. This level is not limited to any particular age. i. Acute functional services (as needed according to benefit package): 2 visits weekly of OT (30 minute sessions) 2 visits weekly of ST (30 minute sessions) 2 visits weekly of PT (30 minute sessions) Behavioral therapy up to 5 hours per week, including a one hour session per week for family/client centered training from BCBA over the course of one year. ii. Sub-Acute Functional Services: 4 visits (30 min) weekly of developmental therapy (combination of OT/PT and/or ST) Behavioral therapy up to 5 hours per month over the course of one year. d. Non-acute Tract: This level serves clients who have fewer needs, are higher functioning and can also serve as a follow up care level. i. Developmental/Functional: Clinical Criteria 5

6 0-4 visits (30 min) weekly (any combination of OT/PT and/or ST) Behavioral therapy up to 2 hours per month over the course of one year. ii. Behavioral: 0-4 visits (30 min) weekly (any combination of OT/PT and/or ST) Behavioral therapy up to 2 hours per month over the course of one year. Exclusions The following services have insufficient or no evidence to support efficacy and do not meet medical necessity: Services that are purely academic and duplicate or replicate academic learning in a school setting Services that are not congruent with this medical policy Cognitive Therapy or retraining Treatment that is considered to be investigational/experimental, including, but not limited to: Auditory Integration Therapy; Facilitated Communication; Floor Time (DIR, Developmental Individual-difference Relationship-based model); Higashi Schools/Daily Life; Individual Support Program; Hyperbaric Oxygen Therapy (HBO); LEAP; SPELL; Waldon; Hanen; Early Bird; Bright Start; Social Stories; Gentle Teaching; Response Teaching Curriculum and Developmental Intervention Model; Holding therapy; Movement Therapy; Music therapy; Pet Therapy; Psychoanalysis; Son-Rise Program; Scotopic Sensitivity training; Sensory Integration training; Neurotherapy (EEG biofeedback); Gluten-free/Casein-free diets; Mega-vitamin therapy; chelation of heavy metals; Anti-fungal drugs for presumed fungal infection; Secretin administration Respite, shadow, para-professional, or companion services in any setting. ABA services in residential facilities to replace or augment the internal behavioral health or ABA program. Custodial care with focus on activities of daily living - bathing, dressing, eating and maintaining personal hygiene, etc. - that do not require the special attention of trained/professional ABA staff Any program or service performed in nonconventional settings (even if the services are performed by a licensed provider), including: spas/resorts; academic, vocational or recreational settings; Outward Bound; and wilderness, camp or ranch programs Exclusion Definitions: Custodial Treatment: Clinical Criteria 6

7 Non-skilled, personal care Examples include: help with activities of daily living, such as bathing, dressing, eating, getting in or out of a bed or chair, moving around, using the bathroom, preparing special diets, and taking medications Care designed for maintaining the safety of the member or anyone else Care with the sole purpose of maintaining and monitoring an established treatment program. Respite Care: care that provides respite for the individual s family or persons caring for the individual. Interpersonal Care: interventions that do not diagnose or treat a disease, and that provide either improved communication between individuals, or a social interaction replacement Social Care: constant observation to prevent relapse during earliest phase of detoxification. There is no medical component. It is delivered by peers, not qualified health care professionals. Paraprofessional Care: services provided by unlicensed persons to help maintain behavior programs designed to allow inclusion of members in structured programs or to support independent living goals except as identified in state mandates or benefit provisions. Medical Necessity Approvals to be made by: Medical Director Physician Reviewer Medical Services Coordinator Nurse Reviewer Authorized CCD staff when UM criteria are met These criteria apply to the following products when determined to be included in the member s benefit package: Commercial Medicare References: Florida Statutes and cited as the Steven A. Geller Autism Coverage Act Remington, B., et al. Early intensive behavioral intervention: outcomes for children with autism and their parents after two years. Am J Ment Retard Nov; 112(6): Reichow B, et al. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev Oct 17; 10:CD Dawson G, et al. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics Jan; 125(1):e17-23 Approved: UMWG 12/3/2015 Approved QIMT 12/09/2015 Capital Health Plan reserves the right to make changes to these criteria at any time to accommodate changes in medical necessity and industry standards. Clinical Criteria 7