autism spectrum disorders medical diagnosis and treatment/media/3d306b9b93cb43a490fd3f3b3... ·...

Autism Spectrum Disorders Medical Diagnosis and Treatment

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy

Autism Spectrum Disorders Medical Diagnosis and Treatment Policy Number: OCA 3.724 Version Number: 9 Version Effective Date: 08/01/17

Product Applicability

All Plan+ Products

Well Sense Health Plan New Hampshire Medicaid NH Health Protection Program

Boston Medical Center HealthNet Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options

only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary

The Plan covers the medical diagnosis and treatment of autism spectrum disorders (ASD) when medically necessary. Treatment for autism includes habilitative or rehabilitative care, pharmacy care, psychiatric care, psychological care, and/or therapeutic care. The Plan complies with coverage guidelines for all applicable state-mandated benefits and federally-mandated benefits that are medically necessary for the member’s condition. Services for autism are provided by the Plan’s contracted providers, and services listed in this policy require prior authorization from the Plan.

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Review the Plan’s Prior Authorization/Notification Requirements matrix for a list of services that require prior authorization. Reference the Plan’s Prior Authorization CPT/HCPCS Code Look-up Tools for the prior authorization requirement for each of the service’s applicable, industry-standard billing code. The prior authorization matrix, code look-up tools, Plan medical policies, Plan pharmacy policies, and Plan reimbursement policies are available at www.bmchp.org for BMC HealthNet Plan members. It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested indication. See Plan policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment. Contact Beacon Health Strategies, LLC at 1-888-217-3501 or at www.beaconhealthstrategies for prior authorization review and approval of behavioral health services. See the BMC HealthNet Plan member’s applicable benefit documents at www.bmchp.org for the most up-to-date information on benefit coverage for behavioral health services and other medically necessary services for autism spectrum disorders (or at www.SeniorsGetMore.org for a Senior Care Options member). Contact eviCore healthcare (formerly known as MedSolutions, Inc.) at 1-888-693-3211 or at www.medsolutionsonline.com to submit prior authorization requests for all outpatient, non-emergent magnetic resonance imaging (MRI/MRA), computed tomography (CT), and positron emission tomography (PET). Review Plan policy, Genetic Testing for Fragile X-Associated Disorders, policy number OCA 3.571, for genetic testing guidelines for an adult or pediatric member with developmental delay, autism spectrum disorder with developmental delay, mental retardation, and/or has an at-risk condition (as specified in the Medical Policy Statement section of the applicable policy). See Plan policy, Genetic Testing Guidelines and Pharmacogenetics, policy number OCA 3.727, for Plan guidelines for genetic testing indications that may include but are not limited to the following: genetic testing for MECP2 sequence variants to diagnosis Rett syndrome and other disorders, limitations related to testing with X-linked intellectual disability (XLID) multigene panels, and limitations related to testing using multiple–single nucleotide polymorphisms (SNPs) to identify the risk of autism spectrum disorders. See Plan policy, Chromosomal Microarray Analysis for Unexplained Intellectual Disabilities and/or Multiple Congenital Anomalies, policy number OCA 3.573, for indications for chromosomal/cytogenomic microarray testing; indications not included in this Plan policy are included in the Genetic Testing Guidelines and Pharmacogenetics, policy number OCA 3.727. Review Plan policy, Preimplantation Genetic Testing (Preimplantation Genetic Diagnosis and Preimplantation Genetic Screening), policy number OCA 3.726, for medical guidelines for preimplantation genetic testing for fragile X syndrome; preimplantation genetic testing is a covered service for some BMC HealthNet Plan members, as specified in the member’s applicable benefit documents available at www.bmchp.org.

Description of Item or Service

Autism Spectrum Disorders Diagnostic Services and Treatment: Services include the diagnosis and treatment of autism spectrum disorders (ASD), which are characterized by varying degrees of impairment in communication skills, reciprocal social interactions, and restricted, repetitive and stereotyped patterns of behavior, speech and interests. Diagnostic and Statistical Manual of Mental Disorders (DSM) is the manual used by clinicians and researchers to diagnose and classify mental

http://www.bmchp.org/

http://www.beaconhealthstrategies/

http://www.seniorsgetmore.org/

http://www.medsolutionsonline.com/



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disorders. Beginning with the fifth edition of DSM (DSM-5), the definition of ASD was revised to more accurately diagnosis individuals with autism-related disorders (categorized as mild, moderate, or severe forms of ASD). DSM-5 combined several previously separate diagnoses under the single diagnosis of ASD. The diagnosis of ASD now 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 the catch-all diagnosis of pervasive developmental disorder not otherwise specified. All of these conditions are now considered under one diagnosis, ASD. Rett syndrome is not included in the DSM-5 ASD diagnostic group.

1. Medical Diagnosis:

The diagnosis of ASD involves a two-step process: a developmental screening and a comprehensive evaluation. An assessment by a multidisciplinary team is appropriate to confirm the diagnosis and would include a licensed family practitioner or general pediatrician, developmental pediatrician, neurologist, psychologist, psychiatrist, speech therapist, and/or other professionals that diagnose children with ASD. The screening and evaluation include medically necessary medical assessments and observation, evaluations of behavior, screening tools (e.g., M-CHAT modified checklist to diagnosis autism in toddlers), genetic testing (as specified in applicable Plan policies outlined in the Summary section of this policy), brain MRI for certain patients (according to prior authorization criteria from eviCore) and/or additional testing for conditions which may include but are not limited to the following, as specified below in items a through i: a. Genetic syndromes (e.g., fragile X syndrome) or prenatal trauma (e.g., fetal alcohol

syndrome) b. Hearing impairments c. Lead poisoning d. Mental retardation e. Neurofibromatosis or tuberous sclerosis (types of neurocutaneous syndromes) f. Seizure disorders g. Specific language impairments h. Visual impairments; AND/OR i. Rule out other (non-ASD) causes of developmental delays



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Once the developmental screening and the comprehensive evaluation are completed for the individual, a definitive diagnosis of ASD is made by a Neurologist, Pediatric Neurologist, Developmental Pediatrician, Psychologist, Psychiatrist or other licensed physician experienced in the diagnosis and treatment of autism.

2. Medical Treatment: Covered services for treatment include medically necessary habilitative or rehabilitative care and therapeutic care (i.e., services provided by licensed or certified speech therapists, occupational therapists, physical therapists, or social workers).

Medical Policy Statement

The Plan considers services related to the diagnosis and/or treatment of autism spectrum disorders (ASD) to be medically necessary when BOTH of the criteria are met and documented in the member’s medical record, as specified below in item 1 and item 2:

1. Criteria Based on Medical Findings:

ALL of the following criteria must be met, as specified below in items a through e:

a. At least ONE (1) of the following clinical conditions is present for the member (as an indication that a conventional developmental milestone is not met), as specified below in items (1) through (5):

(1) Loss of any language or social skills at any age; ∞ OR (2) Absence of babbling by 12 months of age or does not respond to own name by 12

months of age;∞ OR (3) Absence of gesturing (e.g., pointing, waving bye-bye) by 12 months of age;∞ OR (4) Absence of single-word speech by 16 months of age;∞ OR (5) Absence of 2-word spontaneous (not just echolalic) phrases by 24 months of age;∞

AND

∞ Note: According to the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society for the screening and diagnosis of ASD, further evaluation may be required when developmental milestones are not met. Failure to meet these milestones is associated with a high probability of a developmental disability.



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b. There is clear and documented evidence that the symptoms of the illness are active, resulting in substantial impairment in daily functioning (as determined by the treating provider); AND

c. The therapy will achieve functional gains beyond those expected as a result of growth and

maturation; AND d. There is a clear treatment plan with measurable goals and approaches that address the

signs and symptoms of the illness; AND

e. There is no less intensive or more appropriate level of services which can be safely and effectively provided (as determined by the treating provider); AND

2. Service Criteria:

BOTH of the following criteria must be met, as specified below in items a and b:

a. The criteria based on medical findings are met, as specified above in item 1 of this section; AND

b. At least ONE (1) of the following services is provided, as specified below in items (1) through

(8):

(1) Audiologic function test; OR (2) Electroencephalogram (EEG) testing when there is suspicion of a seizure or Plan

criteria are met for video EEG monitoring according to Plan policy, Video Electroencephalography (EEG) Monitoring, policy number OCA 3.38; OR

(3) Evaluation and treatment by a licensed social worker; OR (4) Evaluation and treatment by speech and language pathologist; OR (5) Genetic testing including but not limited to fragile X syndrome (FMR1) and/or

chromosomal analysis or karyotyping when applicable criteria are met, as specified below in at least ONE (1) of the Plan medical policies listed in items (a) through (c): (a) Chromosomal Microarray Analysis for Unexplained Intellectual Disabilities and/or

Multiple Congenital Anomalies, policy number OCA 3.573; OR (b) Genetic Testing for Fragile X-Associated Disorders, policy number OCA 3.571; OR



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(c) Genetic Testing Guidelines and Pharmacogenetics, policy number OCA 3.726; OR (6) Medical evaluation including history and physical examination; OR (7) Speech, occupational and/or physical therapy evaluation and treatment when motor

deficits, motor planning, sensory or speech dysfunction are present; OR (8) Vision evaluation.

Limitations

1. Benefit limits applicable to the rehabilitation therapies benefit do NOT apply to therapeutic care services provided to members with autism spectrum disorders (ASD) when Plan criteria are met for services.

2. Rehabilitative therapy such as physical therapy, occupational therapy, and/or speech therapy

are NOT covered when measurable functional improvement (based on the goals established by the treating provider) is NOT expected or progress has NOT occurred.

3. Any service, program, supply, or procedure administered for personal training and/or life

coaching is NOT covered by the Plan (when applicable criteria are NOT met in the Medical Policy Statement section of this policy).

4. Any service, program, supply, or procedure performed in a non-conventional setting is NOT

covered by the Plan (including but is not limited to the following settings: spas or resorts; educational, vocational, or recreational settings; daycare or preschool settings; or wilderness, camp or ranch programs).

5. The Plan may limit or not cover ANY of the following types of service, as specified below in

items a through e:

a. Service that is educational in nature; b. Service that is provided under an individualized family service plan (ISFP), an individualized

education program (IEP), or an individualized service plan (ISP); c. Service that is provided by school personnel; d. Service that is not medically necessary, including personal training and life coaching;

AND/OR



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e. Service that is considered experimental, investigational, or unproven including but not limited to auditory integration training (AIT), sound therapy, sensory integration therapy/training (SIT), use of a weighted vest, hippotherapy, music, art and recreational therapy, chelation, craniosacral therapy, heavy metal testing, hair analysis. See the following Plan medical policies: Experimental and Investigational Treatment, policy number OCA 3.12 and Complementary and Alternative Medicine (Including Acupuncture Treatment), policy number OCA 3.194.

Contact Beacon Health Strategies, LLC at 1-888-217-3501 or at www.beaconhealthstrategies for prior authorization review and approval of behavioral health services.

Definitions

Applied Behavior Analysis (ABA): Process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior. The methods and principles of ABA have been used to design intensive and comprehensive behavioral treatment programs that attempt to improve outcomes in children, especially young children, who have autism spectrum disorder (ASD). ABA-based programs are generally referred to as intensive behavioral intervention (IBI). The Early Start Denver Model (ESDM) program includes ABA in combination with developmental and relationship-based approaches. Contact Beacon Health Strategies, LLC at 1-888-217-3501 or at www.beaconhealthstrategies for prior authorization review and approval of behavioral health services. See the member’s applicable benefit documents at www.bmchp.org for the most up-to-date information on benefit coverage for behavioral health services. Autism Spectrum Disorders (ASD): A group of biologically-based neurodevelopmental disorders characterized by impairments in three (3) major domains: socialization, communication, and behavior. It has been estimated that as many as 1 in 100 children are affected by ASD. ASD include any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger’s disorder and pervasive developmental disorders not otherwise specified. (Source: Commonwealth of Massachusetts Chapter 207, An Act Relative to Insurance Coverage for Autism.) Board Certified Behavior Analyst: A behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst. (Source: Commonwealth of Massachusetts Chapter 207, An Act Relative to Insurance Coverage for Autism.) Chromosomal/Cytogenomic Microarray Analysis (CMA): Also known as cytogenomic constitutional (genome-wide) microarray analysis, CMA is a high-resolution, whole-genome screening used as a diagnostic tool to identify genetic abnormalities not detected with conventional cytogenetic analysis (e.g., karyotping and FISH). CMA provides more refined testing by detecting smaller deletions and duplications in genomic material, potentially increasing the diagnostic yield in targeted populations.





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CMA collectively describes two (2) different laboratory techniques, comparative genomic hybridization (CGH) and single nucleotide polymorphism (SNP) arrays. See Plan policy, Chromosomal Microarray Analysis for Unexplained Intellectual Disabilities and/or Multiple Congenital Anomalies, policy number OCA 3.573 Developmental Delay: Failure to meet expected developmental milestones due to a significant delay in one (1) or more developmental skills, including gross or fine motor, speech/language, cognitive, social/personal, and/or adaptive development (e.g., activities of daily living or self-care). A significant delay in two (2) or more of these developmental categories is considered global development delay and is thought to predict future intellectual disability. The term ‘developmental delay’ is used with children typically younger than five (5) years old. Developmental Disorder/Developmental Disability: A severe, chronic disability of an individual that is attributable to a mental or physical impairment, or combination of mental and physical impairment, and is manifested before the individual attains the age of 22. The disability is likely to continue indefinitely, results in substantial functional limitations in three (3) or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency. The disability reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized support or other forms of assistance that are of lifelong or of extended duration and are individually planned and coordinated. (Definition is from the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402.) Diagnosis of Autism Spectrum Disorders: Medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing, or other tests to diagnose whether an individual has one (1) of the autism spectrum disorders. (Source: Commonwealth of Massachusetts Chapter 207, An Act Relative to Insurance Coverage for Autism.) Echolalia/Echolalic Phrase: The involuntary parrot-like repetition (echoing) of a word or phrase just spoken by another person. FMR-Related Disorder: A genetic disorder caused by changes in the FMR1 gene, including fragile X syndrome, fragile X-associated tremor/ataxia syndrome, and fragile X-associated primary ovarian insufficiency. Genetic testing may be done on an individual’s DNA with a blood sample or from the DNA of a fetus with a chorionic villus sampling (CVS), amniocentesis sample, or percutaneous umbilical cord blood sampling (PUBS). Fragile X-Associated Disorder: A genetic disorder caused by changes in the FMR1 gene, including fragile X syndrome, fragile X-associated tremor/ataxia syndrome, and fragile X-associated primary ovarian insufficiency. Genetic testing may be done on an individual’s DNA with a blood sample or from the DNA of a fetus with a chorionic villus sampling (CVS), amniocentesis sample, or percutaneous umbilical cord blood sampling (PUBS). See Plan policy, Genetic Testing for Fragile X-Associated Disorders, policy number OCA 3.571.



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Genetic Testing: According to U.S. Library of Medicine, genetic testing is defined as a type of medical test that identifies changes in chromosomes, genes, or proteins. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person’s chance of developing or passing on a genetic disorder. More than 1,000 genetic tests are currently in use, and more are being developed. See Plan policy, Genetic Testing Guidelines and Pharmacogenetics, policy number OCA 3.726. Several methods can be used for genetic testing:

1. Molecular genetic tests (or gene tests) study single genes or short lengths of DNA to identify

variations or mutations that lead to a genetic disorder. 2. Chromosomal genetic tests analyze whole chromosomes or long lengths of DNA to see if there

are large genetic changes, such as an extra copy of a chromosome, that cause a genetic condition.

3. Biochemical genetic tests study the amount or activity level of proteins; abnormalities in either

can indicate changes to the DNA that result in a genetic disorder.

Genetic Testing for Fragile X-Associated Disorders: DNA-based molecular analysis test that detects the fragile X mutation, which is an expansion (lengthening) of trinucleotide repeats CGG within the FMR1 gene. Based on the test results, the patient is classified as normal, intermediate (or “gray zone”), permutation, or full mutation based on the number of CGG repeats. Patients with a full mutation are considered affected with fragile X syndrome; those with a pre-mutation are carriers and may have a FMR1-related disorder such as fragile X-associated primary ovarian insufficiency (FXPOI) or fragile X-associated tremor/ataxia syndrome (FXTAS). See Plan policy, Genetic Testing for Fragile X-Associated Disorders, policy number OCA 3.571 Habilitation Services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. These services are necessary to develop and maintain to the maximum extent practicable the functioning of an individual. Treatment of autism spectrum disorders (ASD) includes the following care prescribed, provided, or ordered for an individual diagnosed with one (1) of the ASD by a licensed physician or a licensed psychologist who determines the care to be medically necessary: habilitative or rehabilitative care, pharmacy care, psychiatric care, psychological care, and therapeutic care. Counseling and guidance services and treatment programs for ASD include but are not limited to applied behavior analysis supervised by a board certified behavior analyst when necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual. Therapeutic care includes services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. (Source: Commonwealth of Massachusetts Chapter 207, An Act Relative to Insurance Coverage for Autism.) Intellectual Disability (ID): As stated by the American Association on Intellectual and Developmental Disabilities (AAIDD), intellectual disability is a disability originating before age 18 which is characterized by significant limitations both in intellectual functioning and in adaptive behavior (including



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conceptual, social, and practical adaptive skills). The degree of ID varies from one individual to another and may range from mild to profound. An individual's level of ID can be defined by their intelligence quotient (IQ) or by the amount and type of support they need. The term ‘intellectual disability’ generally applies to older children where IQ testing is valid and reliable. According to the American Academy of Pediatrics (AAP), the term ‘intellectual disability’ is suggested as an alternative term for ‘mental retardation.’ Karyotype Analysis: Genetic test to examine the number and basic structure of chromosomes in a sample of cells to identify genetic problems as the cause of a disorder or disease. Chromosomes are separated from cells, stained, and arranged in order from largest to smallest so that their number and structure of chromosomes can be studied under a microscope. For example, karyotype can identify an extra copy of chromosome 21 found with Down syndrome. Testing may be done on an individual’s DNA with a blood sample or from the DNA of a fetus with a chorionic villus sampling (CVS), amniocentesis sample, or percutaneous umbilical cord blood sampling (PUBS). Rehabilitation Services: Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. Services are directed at restoring the physical, intellectual, emotional, and/or social functioning of an individual. Treatment of autism spectrum disorders (ASD) includes the following care prescribed, provided, or ordered for an individual diagnosed with one (1) of the ASD by a licensed physician or a licensed psychologist who determines the care to be medically necessary: habilitative or rehabilitative care, pharmacy care, psychiatric care, psychological care, and therapeutic care. Counseling and guidance services and treatment programs for ASD include but are not limited to applied behavior analysis supervised by a board certified behavior analyst that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual. Therapeutic care includes services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. (Source: Commonwealth of Massachusetts Chapter 207, An Act Relative to Insurance Coverage for Autism.) Rett Syndrome: A rare neurological and developmental genetic disorder that occurs mostly in females. Infants and children with Rett syndrome initially appear to grow and develop normally, but between the ages of three (3) months and three (3) years of age, the individual stops developing and may lose some developed skills. (Source: U.S. National Library of Medicine.) Rett syndrome is not included in the autism spectrum disorders diagnosis group in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Applicable Coding

The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care



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Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service. Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines. Review the following applicable Plan reimbursement policies: Reimbursement Policy - Physical, Occupational and Speech Rehabilitation Modalities and Therapeutic Procedures (policy number 4.609 for BMC HealthNet Plan products) and Reimbursement Policy - Early and Periodic Screening, Diagnosis and Treatment (policy number 4.3 for BMC HealthNet Plan products). Services listed in the table below require Plan prior authorization. Additional services included in the Medical Policy Statement section (Service Criteria, item 2), do NOT require prior authorization when:

1. The service is NOT included in this applicable coding list; AND 2. The service does NOT require prior authorization, as specified in the Prior Authorization/

Notification Requirements matrix or in the applicable Plan medical policy available at www.bmchp.org.

CPT Codes Description: Codes Covered When Medical Necessary (When Billed with an ICD10 Code Listed Below) and Prior Authorization is Required

92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Plan note: The initial evaluation for speech therapy does NOT require Plan prior authorization. Therapeutic treatment and re-evaluations do REQUIRE prior authorization, as specified in the following Plan medical policies (applicable for services provided to BMC HealthNet Plan members): Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 21 Years of Age or Older in the

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Outpatient Setting (policy number OCA 3.551) and Speech, Language, Swallowing, Feeding or Voice Therapy for a Member 20 Years of Age or Younger in the Outpatient Setting (policy number OCA 3.55).

92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

97010-97028 Physical medicine and rehabilitation modalities, supervised, code range

97032-97039 Physical medicine and rehabilitation modalities, constant attendance, code range

97110-97530 Therapeutic procedures, code range (Including applicable re-evaluation codes for occupational therapy and physical therapy) Plan note: The initial evaluation for occupational therapy and/or physical therapy does NOT require prior authorization. Therapeutic treatment and/or re-evaluations do REQUIRE prior authorization, as specified in the following Plan medical policies (applicable for services provided to BMC HealthNet Plan members): Occupational Therapy in the Outpatient Setting (policy number OCA 3.53) and Physical Therapy in the Outpatient Setting (policy number OCA 3.54).

ICD-10 Diagnosis Codes

Description

F84.0 Autistic disorder

F84.3 Other childhood disintegrative disorder

F84.5 Asperger's syndrome

F84.8 Other pervasive developmental disorder

F84.9 Pervasive developmental disorder, unspecified

See the following Plan medical policies for medical criteria and prior authorization requirements for associated services:

1. Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder, policy number OCA 3.82

2. Chromosomal Microarray Analysis for Unexplained Intellectual Disabilities and/or Multiple

Congenital Anomalies, policy number OCA 3.573

3. Genetic Testing for Fragile X-Associated Disorders, policy number OCA 3.571 4. Genetic Testing Guidelines and Pharmacogenetics, policy number OCA 3.726 5. Occupational Therapy Guidelines in the Outpatient Setting, policy number OCA 3.53



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6. Physical Therapy Guidelines in the Outpatient Setting, policy number OCA 3.54

7. Preimplantation Genetic Testing (Preimplantation Genetic Diagnosis and Preimplantation Genetic Screening), policy number OCA 3.726

8. Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 20 Years of Age or Younger in the Outpatient Setting, policy number OCA 3.55

9. Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member21

Years of Age or Older in the Outpatient Setting, policy number OCA 3.551

10. Video Electroencephalography (EEG) Monitoring, policy number OCA 3.38

Clinical Background Information

Autism spectrum disorders (ASD) can range from the mild, moderate or severe forms, with varying degrees of impairment in communication skills, social interactions, and restricted, repetitive and stereotyped patterns of behavior. Although ASD varies significantly in character and severity, it occurs in all ethnic and socioeconomic groups and affects every age group. Autism spectrum disorder can be diagnosed as early as 18 months of age or younger in some children. Two other rare, very severe disorders, including Rett syndrome and childhood disintegrative disorder, fall under the umbrella category of PDD but are not considered an ASD (but individuals with these conditions may also meet the diagnostic criteria for an autism spectrum disorder). The diagnosis of an ASD is based on a combination of behavioral characteristics of impairment in verbal and nonverbal communication skills and social interactions, and restricted, repetitive, and stereotyped patterns of behavior, and these can range in impact from mild to significantly disabling. The earliest signs of ASD may include poor eye contact and visual tracking, lack of smiling or imitation of others and absence of babbling and early language. Screening by a pediatrician may begin as early as 9 months of age. Later signs of ASD include odd repetitive behavior, restricted interest, and lack of social skills.

Currently, there is no known cause of ASD. There are a number of research efforts underway to review the biologic basis of ASD. The diagnosis of an ASD lasts throughout an individual’s lifetime with a mild to severe impact on an individual’s level of functioning.

There is currently no cure for ASD, nor is there any one single treatment. ASD symptoms may be managed to a varying extent through a combination of therapies, including behavioral, pharmacological, and educational interventions. The goal of treatment for autistic patients is to minimize the severity of symptoms of autism, maximize learning, facilitate social integration, and improve quality of life for both autistic individuals and their families or caregivers. Treating an ASD is complex and costly because treatments must be intensive. The needs of individuals diagnosed with ASD are quite heterogeneous. There is no single protocol for treating an individual with ASD. Many children receive a combination of interventions, including educational and therapeutic approaches, in



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response to the range of impact on a person’s functioning. Other treatments may also be used to address a range of medical conditions including but not limited to: motor and sensory impairments, seizures, immunological and metabolic abnormalities, sleep problems, and gastrointestinal symptoms. Recommendations for evaluation and assessment of ASD are published by the American Academy of Neurology (Filipek, 2000), the Child Neurology Society and the American Academy of Pediatrics (Johnson, 2007) and the American Academy of Child and Adolescent Psychiatry (Volkmar,1999). According to the American Academy of Pediatrics, medically necessary health care interventions for children with ASD are evidence based, evidence informed, or based on consensus advisory opinion; interventions are recommended by recognized, qualified health care professionals to promote optimal growth and development in a child and to prevent, detect, diagnose, treat, ameliorate, or palliate the effects of physical, genetic, congenital, developmental, behavioral, or mental conditions, injuries, and/or disabilities. The Plan covers the diagnosis and medically necessary treatment of ASD according to Chapter 207 of the Acts of 2010 - An Act Relative to Insurance Coverage for Autism (ARICA) in the state of Massachusetts applicable for fully-insured private insurers. In Massachusetts, coverage for treating ASD is provided by the Early Intervention (EI) program for children between birth and 3 years of age and by school districts for students between 3 and 22 years of age. School districts, which play a key role in treating ASD, remain obligated to provide services under an individualized education program (IEP) to children. In accordance with the federal Individuals with Disabilities Education Act (IDEA), all children in Massachusetts are entitled to receive a free, appropriate public education (FAPE). The state is required to enforce this law. However, wide variation exists in the level and quality of services provided to individuals with ASD among school districts, because of the way in which special education is funded in Massachusetts. MassHealth is not subject to ARICA. While MassHealth covers some treatments (with some children are covered under the Autism Waiver), there may be less autism coverage available, including coverage of applied behavior analysis services. At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) for the medical diagnosis and/or treatment of autism spectrum disorders (ASD). Determine if applicable CMS criteria are in effect for the specified service and the indication for treatment in a national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member.

References

American Academy of Child and Adolescent Psychiatry (AACAP). Volkmar F, Siegel M, Woodbury-Smith M, King B, McCracken J, State M; AACAP Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2014 Feb;53(2):237-57. doi: 10.1016/j.jaac.2013.10.013. PMID: 24472258. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/24472258

https://www.ncbi.nlm.nih.gov/pubmed/24472258



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American Academy of Neurology and the Child Neurology Society. Filipek PA, Accardo PJ, Ashwal S, Baranek GT, Cook EH Jr, Dawson G, Gordon B, Gravel JS, Johnson CP, Kallen RJ, Levy SE, Minshew NJ, Ozonoff S, Prizant BM, Rapin I, Rogers SJ, Stone WL, Teplin SW, Tuchman RF, Volkmar FR. Practice parameter: screening and diagnosis of autism: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000 Aug 22;55(4):468-79. The guideline was reaffirmed by the developer on October 18, 2003, July 28, 2006, and July 10, 2010. Accessed at: http://www.neurology.org/content/55/4/468.full American Academy of Pediatrics (AAP). Autism A.L.A.R.M. Pediatrics, November 2007. Accessed at: https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-Children-with-Disabilities/Documents/AutismAlarm.pdf American Academy of Pediatrics (AAP). Committee on Children with Disabilities. Auditory Integration Training and Facilitated Communications for Autism. Pediatrics. Vol. 102. No. 2. August 1, 1998. pp. 431-433. Statement of reaffirmation for this policy was published on February 1, 2010. Accessed at: http://pediatrics.aappublications.org/content/102/2/431.full American Academy of Pediatrics (AAP). Identification and Evaluation of Children With Autism Spectrum Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) from the American Psychiatric Association. Pediatrics. November 2007. Vol. 120 No. 5 1183-1215. doi: 10.1542/peds.2007-2361. Accessed at: http://pediatrics.aappublications.org/content/120/5/1183 American Academy of Pediatrics (AAP). Johnson CP, Myers, SM, and the AAP Council on Children with Disabilities Identification and Evaluation of Children with Autism Spectrum Disorders. Pediatrics. November 2007; 120:5 1183-1215. Accessed at: http://pediatrics.aappublications.org/content/120/5/1183.full?sid=bec3386f-8676-4216-9043-528f104a16cc American Academy of Pediatrics (AAP). Moeschler JB and Shevell M. Clinical Report. Comprehensive Evaluation of the Child with Intellectual Disability or Global Developmental Delays. AAP Committee on Genetics 2013-2014. Pediatrics Vol. 134 No. 3 September 1, 2014. pp. e903-e918. doi: 10.1542/peds.2014-1839. Accessed at: http://pediatrics.aappublications.org/content/134/3/e903.full?sid=a35732c0-a678-4ead-81e4-7eba2bb6eef5 American College of Medical Genetics and Genomics (ACMG). South ST, Lee C, Lamb AN, Higgins AW, Kearney HM; Working Group for the ACMG Laboratory Quality Assurance Committee. ACMG Standards and Guidelines for constitutional cytogenomic microarray analysis, including postnatal and prenatal applications: revision 2013. Genet Med. 2013 Nov;15(11):901-9. doi: 10.1038/gim.2013.129. Epub 2013 Sep 26. PMID: 24071793. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/24071793

http://www.neurology.org/content/55/4/468.full

https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-Children-with-Disabilities/Documents/AutismAlarm.pdf

https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-Children-with-Disabilities/Documents/AutismAlarm.pdf

http://pediatrics.aappublications.org/content/102/2/431.full

http://pediatrics.aappublications.org/content/120/5/1183

http://pediatrics.aappublications.org/content/120/5/1183.full?sid=bec3386f-8676-4216-9043-528f104a16cc

http://pediatrics.aappublications.org/content/120/5/1183.full?sid=bec3386f-8676-4216-9043-528f104a16cc

http://pediatrics.aappublications.org/content/134/3/e903.full?sid=a35732c0-a678-4ead-81e4-7eba2bb6eef5

http://pediatrics.aappublications.org/content/134/3/e903.full?sid=a35732c0-a678-4ead-81e4-7eba2bb6eef5

https://www.ncbi.nlm.nih.gov/pubmed/24071793



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American Psychiatric Association (APA). Autism Spectrum Disorder. Changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 2013. Accessed at: http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Accessed at: https://www.psychiatry.org/psychiatrists/practice/dsm American Speech-Language-Hearing Association (ASHA). Auditory Integration Training. Position Statement. 2004. Accessed at: http://www.asha.org/policy/TR2004-00260.htm American Speech-Language-Hearing Association (ASHA). State Insurance Mandates for Autism Spectrum Disorder. States with Specific Autism Mandates. Accessed at: http://www.asha.org/Advocacy/state/States-Specific-Autism-Mandates/ Blackmon K. Structural MRI biomarkers of shared pathogenesis in autism spectrum disorder and epilepsy. Epilepsy Behav. March 23, 2015. PMID: 25812936. Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder. Accessed at: http://www.cdc.gov/ncbddd/autism/index.html Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder. Diagnostic Criteria. Accessed at: http://www.cdc.gov/ncbddd/autism/hcp-dsm.html Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder. Recommendations and Guidelines. Accessed at: https://www.cdc.gov/ncbddd/autism/hcp-recommendations.html Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder. Screening and Diagnosis for Healthcare Providers. Accessed at: https://www.cdc.gov/ncbddd/autism/hcp-screening.html Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder. Signs and Symptoms. Accessed at: http://www.cdc.gov/ncbddd/autism/signs.html Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder. Treatment. Accessed at: http://www.cdc.gov/ncbddd/autism/treatment.html Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx The Commonwealth of Massachusetts. The Massachusetts Autism Commission Report. Report from the Governor’s Special Commission Relative to Autism. 2013. Accessed at: http://www.mass.gov/anf/docs/mddc/autism-commission-report-full.pdf

http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf

https://www.psychiatry.org/psychiatrists/practice/dsm

http://www.asha.org/policy/TR2004-00260.htm

http://www.asha.org/Advocacy/state/States-Specific-Autism-Mandates/

http://www.cdc.gov/ncbddd/autism/index.html

http://www.cdc.gov/ncbddd/autism/hcp-dsm.html

https://www.cdc.gov/ncbddd/autism/hcp-recommendations.html

https://www.cdc.gov/ncbddd/autism/hcp-screening.html

http://www.cdc.gov/ncbddd/autism/signs.html

http://www.cdc.gov/ncbddd/autism/treatment.html

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

http://www.mass.gov/anf/docs/mddc/autism-commission-report-full.pdf



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Division of Health Care Finance and Policy (DHCFP). Review and Evaluation of Proposed Legislation Entitled: An Act Relative to Insurance Coverage for Autism House Bill 3809 Provided for The Joint Committee on Financial Services. March 2010. eMedicineHealth. Medical Definition of Echolalia. Accessed at: http://www.emedicinehealth.com/script/main/art.asp?articlekey=26315 Habilitation Benefits Coalition. Coverage of Habilitation Services and Devices in the Essential Benefits Package under the Affordable Care Act. Definitions of Habilitative Services and Rehabilitative Services. Accessed at: http://www.aucd.org/docs/urc/TA%20Institute%202013/Habilitation%20White%20Paper%20(final)%20(D0391656)%20(3).pdf Hayes Medical Technology Directory. Applied Behavior Analysis-Based Interventions for Autism Spectrum Disorder. Winifred Hayes, Inc. December 9, 2014. Annual Review November 21, 2016. Hayes Medical Technology Directory. Social Skills Training for Autistic Spectrum Disorders. Winifred Hayes, Inc. October 17, 2013. Annual Review October 7, 2015. Hayes Search & Summary. Speech Generating Devices for Autism. Winifred Hayes, Inc. December 15, 2016. Knipper S. EPSDT: Supporting Children with Disabilities. National Center for Family Support. Human Services Research Institute. Prepared for the Administration on Developmental Disabilities, Administration for Children and Families. U.S. Department of Health and Human Services. September 2004. Levy SE, Hyman SL. Complementary and alternative medicine treatments for children with autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2015 Jan;24(1):117-43. PMID: 25455579. MedlinePlus. Rett Syndrome. U.S. National Library of Medicine. Accessed at: https://medlineplus.gov/rettsyndrome.html

Michelson DJ, Shevell MI, Sherr EH, Moeschler JB, Gropman AL, Ashwal S. Evidence report: Genetic and metabolic testing on children with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2011 Oct 25;77(17):1629-35. PMID: 21956720.

http://www.emedicinehealth.com/script/main/art.asp?articlekey=26315

http://www.aucd.org/docs/urc/TA%20Institute%202013/Habilitation%20White%20Paper%20(final)%20(D0391656)%20(3).pdf

http://www.aucd.org/docs/urc/TA%20Institute%202013/Habilitation%20White%20Paper%20(final)%20(D0391656)%20(3).pdf

https://medlineplus.gov/rettsyndrome.html



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Miller DT, Adam MP, Aradhya S, Biesecker LG, Brothman AR, Carter NP, Church DM, Crolla JA, Eichler EE, Epstein CJ, Faucett WA, Feuk L, Friedman JM, Hamosh A, Jackson L, Kaminsky EB, Kok K, Krantz ID, Kuhn RM, Lee C, Ostell JM, Rosenberg C, Scherer SW, Spinner NB, Stavropoulos DJ, Tepperberg JH, Thorland EC, Vermeesch JR, Waggoner DJ, Watson MS, Martin CL, Ledbetter DH. Consensus statement: chromosomal microarray is a first-tier clinical diagnostic test for individuals with developmental disabilities or congenital anomalies. Am J Hum Genet. 2010 May 14;86(5):749-64. PMID: 20466091. Moeschler JB, Shevell M; Committee on Genetics. Comprehensive evaluation of the child with intellectual disability or global developmental delays. Pediatrics. 2014 Sep;134(3):e903-18. PMID: 25157020. National Institutes of Health. Rett Syndrome: Overview. U. S. Department of Health and Human Services. Accessed at: https://www.nichd.nih.gov/health/topics/rett/Pages/default.aspx National Institute of Mental Health (NIMH). Autism Spectrum Disorder. Accessed at: http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml New Hampshire Medicaid Waiver. Disability Services & Waivers. What is considered a developmental disability in New Hampshire? Accessed at: http://medicaidwaiver.org/state/new_hampshire.html Scottish Intercollegiate Guidelines Network (SIGN). Assessment, diagnosis and clinical interventions for children and young people with autism spectrum disorders. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2007 Jul. 65 p. (SIGN publication; no. 98). Accessed at: http://www.guideline.gov/content.aspx?id=11011&search=autism Shen Y, Dies KA, Holm IA, Bridgemohan C, Sobeih MM, Caronna EB, Miller KJ, Frazier JA, Silverstein I, Picker J, Weissman L, Raffalli P, Jeste S, Demmer LA, Peters HK, Brewster SJ, Kowalczyk SJ, Rosen-Sheidley B, McGowan C, Duda AW 3rd, Lincoln SA, Lowe KR, Schonwald A, Robbins M, Hisama F, Wolff R, Becker R, Nasir R, Urion DK, Milunsky JM, Rappaport L, Gusella JF, Walsh CA, Wu BL, Miller DT; Autism Consortium Clinical Genetics/DNA Diagnostics Collaboration. Clinical genetic testing for patients with autism spectrum disorders. Pediatrics. 2010 Apr;125(4):e727-35. PMID: 20231187. Singer A, Ravi R. Complementary and alternative treatments for autism part 2: identifying and avoiding non-evidence-based treatments. AMA J Ethics. 2015 Apr 1;17(4):375-80. PMID: 25901708. State of New Hampshire. New Hampshire Medicaid. Therapies: Physical, Occupational, Speech. Provider Manual Volume II. April 1, 2013. U.S. Preventive Services Task Force. Screening for autism spectrum disorder in young children: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016 Feb 16;315(7):691-6. Accessed at: http://www.guideline.gov/content.aspx?f=rss&id=50034&osrc=12

https://www.nichd.nih.gov/health/topics/rett/Pages/default.aspx

http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml

http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml

http://medicaidwaiver.org/state/new_hampshire.html

http://www.guideline.gov/content.aspx?id=11011&search=autism

http://www.guideline.gov/content.aspx?f=rss&id=50034&osrc=12



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Weissman L, Bridgemohan C. Autism spectrum disorder in children and adolescents: Overview of management. UpToDate.com. February 5, 2015. Zeglam AM, Al-Ogab MF, Al-Shaftery T. MRI or not to MRI! Should brain MRI be a routine investigation in children with autistic spectrum disorders? Acta Neurol Belg. 2014 Oct 26. PMID: 25344829.

Original Approval Date

Original Effective Date* and Version

Number Policy Owner

Original Policy Approved by

Regulatory Approval: N/A Internal Approval: 06/29/11: MPCTAC 07/27/11: QIC

01/01/12 Version 1

Medical Policy Manager as Chair of Medical Policy, Criteria, and Technology Assessment Committee (MPCTAC)

MPCTAC and Quality Improvement Committee (QIC)

* Effective Date for Senior Care Options Product(s): 01/01/16.

Policy Revisions History

Review Date

Summary of Revisions

Revision Effective Date and Version

Number

Approved by

06/01/12

References updated, CPT code list updated to only include services that require Plan prior authorization, and diagnosis codes removed from policy. ‘Audiologic evaluation’ changed to ‘audiologic function test’ in Clinical Guideline Statement section to match CPT code definition of service. Revised the introductory paragraphs in Applicable Coding section.

Version 2 06/20/12: MPCTAC 07/25/12: QIC

06/01/13

Review for effective date 10/01/13. Deleted duplicate text in the Summary, Limitations, and Clinical Background Information sections. Revised Summary, Description of Item or Service, Medical Policy Statement, Limitations, Definitions, and References sections. Added Plan note in Applicable Coding section related to authorization requirements for initial evaluations for occupational therapy, physical therapy, and speech therapy. Referenced applicable Plan policies and prior authorization matrix.

10/01/13 Version 3

06/19/13: MPCTAC 07/18/13: QIC

01/30/14 Off cycle review for effective date 04/01/14. Added ICD10 diagnosis code equivalents of existing ICD9 diagnosis codes.

04/01/14 Version 4

01/27/14: MPCTAC 01/30/14: QIC

05/01/14

Review for effective date 09/01/14. Updated Description of Item or Service, Clinical Background

09/01/14 Version 5

05/21/14: MPCTAC 06/11/14: QIC



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Policy Revisions History

Information, and References sections. Revised language in the Applicable Coding section without changing the applicable code list. Added limitations.

05/01/15 Review for effective date 07/01/15. Removed Commonwealth Choice and Employer Choice from the list of applicable products because the products are no longer available. Revised Description of Item or Service and Clinical Background Information sections to represent the latest diagnostic guidelines of autism spectrum disorders from the Diagnostic and Statistical Manual of Mental Disorders. Updated the Summary and Definitions sections. Administrative changes made to Medical Policy Statement and Limitations sections without changing criteria.

07/01/15 Version 6

05/20/15: MPCTAC 06/10/15: QIC

11/25/15 Review for effective date 01/01/16. Updated template with list of applicable products and corresponding notes. Updated Summary and Description of Item or Service sections. Revised language in the Applicable Coding section

01/01/16 Version 7

11/18/15: MPCTAC 11/25/15: MPCTAC (electronic vote) 12/09/15: QIC

06/01/16 Review for effective date 09/01/16. Updated criteria in the Medical Policy Statement section. Updated Summary, Clinical Background Information, References, and References to Applicable Laws and Regulations sections. Removed the ICD-9 diagnosis codes.

09/01/16 Version 8

05/18/16: MPCTAC 06/08/16: QIC

05/01/17 Review for effective date 08/01/17. Updated Summary, Description of Item or Service, Definitions, References, and Reference to Applicable Laws and Regulations sections. Updated code list and revised notes in the Applicable Coding section. Revised criteria in the Medical Policy Statement and Limitations sections.

08/01/17 Version 9

05/17/17: MPCTAC

Last Review Date

05/01/17

Next Review Date

05/01/18

Authorizing Entity

MPCTAC



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Other Applicable Policies

Medical Policy - Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder, policy number OCA 3.82 Medical Policy - Chromosomal Microarray Analysis for Unexplained Intellectual Disabilities and/or Multiple Congenital Anomalies, policy number OCA 3.573 Medical Policy - Complementary and Alternative Medicine (Including Acupuncture Treatment), policy number OCA 3.194 Medical Policy - Experimental and Investigational Treatment, policy number OCA 3.12 Medical Policy - Genetic Testing for Fragile X-Associated Disorders, policy number OCA 3.571 Medical Policy - Genetic Testing Guidelines and Pharmacogenetics, policy number OCA 3.726 Medical Policy - Medically Necessary, policy number OCA 3.14

Medical Policy - Occupational Therapy Guidelines in the Outpatient Setting, policy number OCA 3.53 Medical Policy - Physical Therapy Guidelines in the Outpatient Setting, policy number OCA 3.54 Medical Policy - Preimplantation Genetic Testing (Preimplantation Genetic Diagnosis and Pregenetic Screening), policy number OCA 3.726 Medical Policy - Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 20 Years of Age or Younger in the Outpatient Setting (policy number OCA 3.55) Medical Policy - Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 21 Years of Age or Older in the Outpatient Setting (policy number OCA 3.551) Medical Policy - Video Electroencephalography (EEG) Monitoring, policy number OCA 3.38 Reimbursement Policy - Early and Periodic Screening, Diagnosis and Treatment, policy number 4.3 Reimbursement Policy - Physical, Occupational and Speech Rehabilitation Modalities and Therapeutic Procedures, policy number 4.609

Reference to Applicable Laws and Regulations

78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf The Commonwealth of Massachusetts. Chapter 207 of the Acts of 2010 - An Act Relative to Insurance Coverage for Autism. Mass. Gen. Laws. ch. 32A §25; ch. 175 §47AA; ch. 176A §8DD ch. 176B §4DD; ch. 176G §4V. Accessed at: https://malegislature.gov/Laws/SessionLaws/Acts/2010/Chapter207 The Commonwealth of Massachusetts. Massachusetts General Laws Mandating that Certain Health Benefits Be Provided By Commercial Insurers, Blue Cross and Blue Shield and Health Maintenance Organizations. Regulatory Citations. May 31, 2016. Accessed at: http://www.mass.gov/ocabr/docs/doi/consumer/healthlists/mndatben.pdf Individuals with Disabilities Education Act (IDEA) of 2004. Accessed at: http://www2.ed.gov/about/offices/list/osers/osep/index.html

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleIV/Chapter32A/Section25

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175/Section47AA

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176A/Section8DD

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176B/Section4DD

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176G/Section4V

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176G/Section4V

https://malegislature.gov/Laws/SessionLaws/Acts/2010/Chapter207

http://www.mass.gov/ocabr/docs/doi/consumer/healthlists/mndatben.pdf

http://www2.ed.gov/about/offices/list/osers/osep/index.html



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Disclaimer Information:

Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs.

Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members.

The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.