Autism Spectrum Disorders Effective: January 1, 2015 Description In May 2013 the American Psychiatric Association (APA) released the 5 th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This edition of the DSM includes several significant changes over the previous edition, including combining several previously separate diagnoses under the single diagnosis of "autism spectrum disorder" (ASD). This diagnosis includes the following 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 (PDD) not otherwise specified. All of these conditions are now considered under one diagnosis, ASD. It should be noted that Rett is not included in the new DSM-5 ASD diagnostic group. The DSM-5 describes the essential diagnostic features of ASD as both a persistent impairment in reciprocal social communication and restricted and repetitive pattern of behavior, interest or activities. These attributes are present from early childhood and limit or impair everyday functioning. Parents may note symptoms as early as infancy, and the typical age of onset is before 3 years of age. Symptoms may include problems with using and understanding language; difficulty relating to or reciprocating with people, objects, and events; lack of mutual gaze or inability to attend events conjointly; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings, and repetitive body movements or behavior patterns. Children with childhood disintegrative disorder are an exception to this description, in that they exhibit normal development for approximately 2 years followed by a marked regression in multiple areas of function. Children with ASD vary widely in abilities, intelligence, and behaviors. Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development. Repetitive play skills, resistance to change in routine and inability to share experiences with others, and limited social and motor skills are generally evident. Unusual responses to sensory information, such as loud noises and lights, are also common. Children unaffected by ASDs can exhibit unusual behaviors occasionally or seem shy around others sometimes without having ASD. What sets children with ASD apart is the consistency of their unusual behaviors. Symptoms of the disorder have to be present in all settings, not just at home or at school, and over considerable periods of time. With ASD, there is a lack of social interaction, impairment in nonverbal behaviors, and a failure to develop normal peer relations. A child with an ASD tends to ignore facial expressions and may not look at others; other children may fail to respect interpersonal boundaries and come too close and stare fixedly at another person. The exact causes of autism are unknown, although genetic factors are strongly implicated. A study released by the Center for Disease Control and Prevention (2012) indicates that the incidence of ASD was as high as 1 in 88.
Policy The following services may be Medically Necessary for the assessment of a member with suspected or known ASD: Medical evaluation (complete medical history and physical examination). behavioral health evaluation including psychiatric examination Parent and/or child interview (including siblings of children with autism). autism-specific developmental screening (Current Procedural Terminology [CPT] code 96110, e.g., Checklist for Autism in Toddlers [CHAT], Pervasive Developmental Disorder Screening Test-II) and CPT code 96111, e.g., Autism Behavior Checklist [ABC], Childhood Autism Rating Scale [CARS]) occupational and/or physical therapy evaluation when motor deficits, motor planning or sensory dysfunction are present Evaluation by speech-language pathologist. Formal audiological hearing evaluation including frequency-specific brainstem auditory evoked response or otoacoustic emissions. Measurement of blood lead level if the child exhibits developmental delay and pica, or lives in a high-risk environment. Additional periodic lead screening can be considered if the pica persists. Genetic counseling for parents of a child with autism. Genetic testing specifically high resolution chromosome analysis (karyotype) and DNA analysis for fragile X syndrome in the presence of developmental delay/intellectual disability (DD/ID) if there is a family history of fragile X or DD/ID) of undetermined etiology, or if dysmorphic features are present. Quantitative plasma amino acid assays to detect phenylketonuria. Selective metabolic testing if the child exhibits any of the following: 1. Clinical and physical findings suggestive of a metabolic disorder (e.g., cyclic vomiting, early seizure, or lethargy); or 2. Dysmorphic or coarse features; or 3. Evidence of DD/ID; or 4. DD/ID can not be ruled out; or 5. Occurrence or adequacy of newborn screening for a birth defect is questionable. Electroencephalogram (EEG) for clinical spells that might represent seizures. The following procedures and services may be Medically Necessary for the treatment of a member diagnosed with ASD: Behavioral health treatment (e.g., behavior modification, family therapy, or other forms of psychotherapy) that are clinically appropriate in terms of type, frequency, extent, site and duration, for management of behavioral symptoms related to ASD may be Medically Necessary when required for the management of behaviors, especially where there is the potential for individuals to harm themselves or others, or when such treatment would otherwise be considered Medically Necessary.
Intensive behavioral interventions (e.g., early intensive behavior intervention [EIBI], intensive behavior intervention [IBI], Early Start Denver Model (ESDM), Lovaas therapy, applied behavior analysis [ABA]) for any indication are Investigative. Some states mandate benefit coverage for applied behavioral analysis for treatment of ASD. In those states, the applicable mandate must be followed. An initial course of ABA treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met: 1. A diagnosis of ASD has been made by a licensed medical professional or licensed psychologist; and 2. The goals of intervention are appropriate for the individual's age and impairments: a. Age 7 and under: Social, communication, or language skills or adaptive functioning that have been identified as deficient relative to age expected norms, which form the basis for an individualized treatment plan. The treatment plan should include treatment with a certified or licensed ABA provider (in accordance with state law and benefit plan requirements) for 25 hours per week or less; and b. Age 8 and over: Behaviors or deficits that are interfering with social, communication or language skills or adaptive functioning form the basis for an individualized treatment plan; and 3. Documentation is provided which describes the individual-specific treatment plan that includes all of the following: a. Addresses the identified behavioral, psychological, family, and medical concerns; and b. Has measurable goals in objective and measurable terms based on standardized assessments that address the behaviors and impairments for which the intervention is to be applied (Note: this should include, for each goal, baseline measurements, progress to date and anticipated timeline for achievement based on both the initial assessment and subsequent interim assessments over the duration of the intervention); and c. Documents that ABA services will be delivered by an appropriate provider who is licensed or certified according to the requirements of applicable state laws and benefit plan requirements Note: Where such requirements apply, the provider of ABA should be within the requirements of the specific state law or as described by the benefit plan. Continuation of ABA treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met: 1. The individual has met criteria for an initial course of ABA; and 2. The individual-specific treatment plan will be updated and submitted, in general, every 6 months or as required by a state mandate. Note: treatment plans may be required more often than every 6 months when warranted by the individual circumstances; and 3. For each goal in the individual-specific treatment plan, the following is documented: a. Developmental testing is done no later than 2 months after the initial course of ABA treatment has begun in order to establish a baseline in the areas of social skills, communication skills, language skills, and adaptive functioning; and b. Progress to date; and c. Anticipated timeline for achievement of the goal based on both the initial assessment and subsequent interim assessments over the duration of the intervention; and 4. The individual-specific treatment plan includes age and impairment appropriate goals and measures of progress:
a. Age 7 and under: The treatment plan should include measures of the progress made with social skills, communication skills, language skills and adaptive functioning. Clinically significant progress in social skills, communication skills, language skills, and adaptive functioning must be documented as follows: i. Interim progress assessment at least every six months based on clinical progress toward treatment plan goals; and ii. Developmental status as measured by standard scores using standardized assessments every 1 to 2 years.* b. Age 8 and over: The treatment plan should include measures of the specific behaviors or deficits targeted and also include assessments of social skills, communication skills, language skills, and adaptive functioning that reflect progress in the areas that were identified as negatively affected by the targeted behaviors and deficits. Clinically significant progress in social skills, communication skills, language skills, and adaptive functioning must be documented as follows: i. Interim progress assessment at least every six months based on clinical progress toward treatment plan goals; and ii. Developmental status as measured by standard scores using standardized assessments every 2 to 3 years.* Supervision of behavior analysts providing ABA treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met: 1. The individual has been approved for covered benefits based on criteria above; and 2. The supervising professional is an appropriate provider who is licensed or certified according to the requirements of applicable state laws and benefit plan requirements to perform the supervisory services; and 3. Generally, one (1) hour of supervision will be covered for every ten (10) to twenty (20) hours of direct ABA therapy. Any greater frequency of supervision will require written documentation demonstrating the need for additional supervision. Psycho-pharmacotherapy for management of target symptoms or co-morbidities related to ASD may be Medically Necessary. Note: Coverage of pharmacotherapy is subject to the member's specific benefits for drug coverage. Please check benefit plan descriptions. BCBSNE has determined the following procedures and services to be Investigative as the peer-reviewed medical literature has been determined to be insufficient to find them to be Scientifically Validated in the assessment and treatment of ASD/PDD: Assessment: Allergy testing (including food allergy for gluten, casein, candida, and other molds; allergen specific IgG and IgE) Electronystagmography (in the absence of dizziness, vertigo, or balance disorder) Erythrocyte glutathione peroxidase studies Event-related brain potentials Hair analysis for trace elements Intestinal permeability studies Magnetoencephalography/magnetic source imaging Neuroimaging studies such as CT, functional MRI (fmri), MRI, MRS, PET, and SPECT Nutritional testing (e.g., testing for arabinose and tartaric acid)
Provocative chelation tests for mercury Stool analysis Tests for celiac antibodies Tests for homocysteine Tests for immunologic or neurochemical abnormalities Tests for micronutrients such as vitamin levels Tests for mitochondrial disorders including lactate and pyruvate Tests for thyroid function Tests for urinary peptides Tests for amino acids (except quantitative plasma amino acid assays to detect phenylketonuria), fatty acids (non-esterified), organic acids, citrate, silica, urine vanillylmandelic acid Tests for heavy metals (e.g., antimony, arsenic, barium, beryllium, bismuth, mercury) Tests for trace metals (e.g., aluminum, cadmium, chromium, copper, iron, lead, lithium, magnesium, manganese, nickel, selenium, zinc) Tympanometry (in the absence of hearing loss). Treatment: Acupuncture Anti-fungal medications (e.g., fluconazole, ketoconizole, metronidazole, nystatin) Anti-viral medications (e.g., acyclovir, amantadine, famciclovir, isoprinosine, oseltamivir, valacyclovir) Auditory integration training (auditory integration therapy) Chelation Therapy Cognitive rehabilitation Elimination diets (e.g., gluten and milk elimination) Facilitated communication Herbal remedies (e.g., astragalus, berberis, echinacea, garlic, plant tannins, uva ursi) Floor time therapy Holding therapy Immune globulin infusion Manipulative therapies Massage therapy Music therapy and rhythmic entrainment interventions Neurofeedback/EEG biofeedback Nutritional supplements (e.g., dimethylglycine, glutathione, magnesium, megavitamins, omega- 3 fatty acids, and high-dose pyridoxine) Secretin infusion Sensory integration therapy (see Medical Policy VII.49) Stem cell transplantation Systemic hyperbaric oxygen therapy Tomatis sound therapy Vision therapy Vitamins and minerals (calcium, germanium, magnesium, manganese, selenium, tin, tungsten, vanadium, zinc, etc.). Weighted blankets/vests.