Subject:
Comprehensive Programs for the Management of Autism Spectrum Disorders
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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One of the most important changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-V) is to autism spectrum disorder (ASD). The revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders.
Using DSM-IV, patients could be diagnosed with four separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder, or the catch-all diagnosis of pervasive developmental disorder not otherwise specified. Researchers found that these separate diagnoses were not consistently applied across different clinics and treatment centers. Anyone diagnosed with one of the four pervasive developmental disorders (PDD) from DSM-IV should still meet the criteria for ASD in DSM-5 or another, more accurate DSM-5 diagnosis. While DSM does not outline recommended treatment and services for mental disorders, determining an accurate diagnosis is a first step for a clinician in defining a treatment plan for a patient.
People with ASD tend to have social deficits, such as responding inappropriately in conversations, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. Again, the symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having much more severe symptoms. This spectrum will allow clinicians to account for the variations in symptoms and behaviors from person to person.
Under the DSM-5 criteria, individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later. This criteria change encourages earlier diagnosis of ASD but also allows people whose symptoms may not be fully recognized until social demands exceed their capacity to receive the diagnosis. It is an important change from DSM-IV criteria, which was geared toward identifying school-aged children with autism-related disorders, but not as useful in diagnosing younger children.42
Children with Rett’s Disorder, seen almost exclusively in girls, which is a sex-linked genetic disorder characterized by inadequate brain growth, seizures, and other neurological problems, also may show autistic behavior.
A comprehensive program for the management of ASDs is defined as any nonpharmaceutical treatment that seeks to improve the overall symptomatology of a child with pervasive developmental disorder. These programs emphasize highly structured and often time-intensive (a minumum of 20 hours per week) skill-oriented training that is tailored to the individual child. Therapists work with children to help them develop social and language skills. One aspect common to all comprehensive treatment programs is their emphasis on early intervention.
A number of comprehensive programs are available for children with autism spectrum disorders. Theoretical orientation distinguishes one program from another with some programs being behaviorally oriented and others being developmentally oriented. In brief, behavioral approaches use certain techniques or strategies, collectively referred to as applied behavioral analysis, in a systematic manner to produce observable and socially significant changes in a child's behavior and skills. Unlike behaviorally-oriented programs, most developmental approaches do not rely on a specific set of strategies or techniques to modify behaviors or teach new skills. Instead, developmental programs organize a child's environment to encourage or facilitate communicative and social interactions. Some behaviorally-oriented comprehensive programs include the UCLA Young Autism Program (also known as the Lovaas Model of Applied Behavioral Analysis (ABA), and discrete trial training); the Douglass Program at Rutgers (also known as the Rutgers Autism Program)l; and the Learning Experiences...An Alternative Program for Preschoolers and Parents (LEAP)). Examples of developmentally-oriented comprehensive programs include the Denver Model Program and the Developmental, Individual-differences, Relationship model (DIR model). Examples of comprehensive programs that incorporate both developmental and behavioral methods include the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) Program and the Social Communication, Emotional Regulation, and Transactional Supports (SCERTS) model).
Policy:
[NOTE: For behavioral interventions based on the principles of applied behavioral analysis (ABA) and related structured behavioral programs, refer to a separate policy on Applied Behavioral Analysis in the Treatment of Pervasive Developmental Disorders (PDD)/Autism Spectrum Disorder (ASD) (Policy #120) in the Treatment Section.]
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
Programs used for the management of children with autism spectrum disorders (ASDs) that are called "comprehensive", are done so by the industry, not by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). While there may be certain therapeutic benefits associated with particular elements of these so-called "comprehensive" programs and there may be coverage under a member’s contract for one or more services because they may be a benefit under the contract already, the so-called "comprehensive" programs intact are considered by Horizon BCBSNJ as investigational. There is insufficient evidence of the effectiveness of these types of programs in the published peer reviewed medical literature.
Medicaid Coverage:
FIDE SNP: For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Comprehensive Programs for the Management of Autism Spectrum Disorders
Comprehensive Programs for Pervasive Developmental Disorders
Pervasive Developmental Disorder
PDD
Autism Spectrum Disorder
ASD
Autistic Disorder
Rett’s Disorder
Asperger’s Disorder
Childhood Disintegrative Disorder
Lovaas Program
TEACCH
LEAP
References:
1. ECRI. Comprehensive Programs for the Treatment of Children with Autism. Executive Briefings, February 2000.
2. Alberta Heritage Foundation for Medical Research. Health Technology Assessment: Intensive Intervention Programs for Children with Autism. February, 2001.
3. British Columbia Office of Health Technology Assessment. Autism and Lovaas treatment: A systematic review of effectiveness evidence. June 3, 2001. [Available at http://www.chspr.ubc.ca/files/publications/2001/bco01-13C.pdf (last accessed 09/17/2007).]
4. British Columbia Office of Health Technology Assessment. Center for Health Services and Policy Research: Critical appraisal of submitted cost-benefit models of ‘Lovaas’ early intensive behavioral intervention for autism. February 2000. [Available at http://www.chspr.ubc.ca/files/publications/2000/bco00-28T.pdf (last accessed 09/17/2007).]
5. Chiu S, Leonard H. Pervasive Developmental Disorder. eMedicine. Last updated: July 1, 2003. www.emedicine.com/PED/topic1780.htm (accessed 08/05/03).
6. Brasic JR. Pervasive Developmental Disorder: Asperger Syndrome. eMedicine. Last updated: May 7, 2003. www.emedicine.com/ped/topic147.htm (accessed 8/5/03).
7. The National Institute of Neurological Disorders and Stroke (NINDS). Pervasive Developmental Disorders Information Page. Last updated: July 31, 2007. [Available at http://www.ninds.nih.gov/disorders/pdd/pdd.htm (last accessed 09/17/2007).
8. The National Institute of Neurological Disorders and Stroke (NINDS). Asperger Syndrome Information Page. Last updated: July 31, 2007. [Available at http://www.ninds.nih.gov/disorders/asperger/asperger.htm (last accessed 09/17/2007).]
9. The National Institute of Neurological Disorders and Stroke (NINDS). Autism Information Page. Last updated: July 31, 2007. [Available at http://www.ninds.nih.gov/disorders/autism/detail_autism.htm (last accessed 09/17/2007).]
10. Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol. 1987 Feb;55(1):3-9.
11. McEachin JJ, Smith T, Lovaas OI. Long-term outcome for children with autism who received early intensive behavioral treatment. Am J Ment Retard. 1993 Jan;97(4):359-72; discussion 373-91.
12. The National Autistic Society. What is the Lovaas? Last updated: August 2008. Available at: http://www.nas.org.uk/nas/jsp/polopoly.jsp?d=1390&a=3345
13. National Information Center for Children and Youth with Disabilities. Autism and Pervasive Developmental Disorder (PDD). Fact Sheet No. 1 (FS1), April 2007. [Available at http://www.autismweb.com/info.htm (last accessed 09/17/2007).]
14. Blue Cross Blue Shield Association. Technology Evaluation Center (TEC) Assessment Program. Sensory Integration Therapy. Vol. 14, No. 22, February 2000.
15. DSM-IV Criteria, Pervasive Developmental Disorders. Diagnostic and Statistical Manual, 4th Edition, 1994, American Psychiatric Association. www.autism-biomed.org/dsm-iv.htm (accessed 08/05/03).
16. Prater CD, Zylstra RG. Autism: a medical primer. Am Fam Physician. 2002 Nov 1;66(9):1667-74.
17. Lonigan CJ, Elbert JC, Johnson SB. Empirically supported psychosocial interventions for children: an overview. J Clin Child Psychol 1998 Jun;27(2):138-45.
18. Committee on Children With Disabilities, American Academy of Pediatrics. Technical report: the pediatricians’ role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics. 2001 May;107(5):E85 [Full text article available at: http://pediatrics.aappublications.org/cgi/reprint/107/5/e85 ]
19. Early intervention for children with autism. Position Statement (No. PP 2004-02). Canadian Pediatric Society. Posted April 2004. [Available at: http://www.cps.ca/english/statements/PP/pp04-02.pdf (accessed 8/31/2006).]
20. Auditory integration training and facilitated communication for autism. American Academy of Pediatrics. Committee on Children with Disabilities. Pediatrics. 1998 Aug;102(2 Pt 1):431-3.
21. ECRI Hotline Response: Auditory Integration Training for Behavioral, Emotional and Hearing Disorders. Updated 02/03/05.
22. ECRI Institute. Health Technology Assessment Information Service (HTAIS). Custom Hotline Response: Comprehensive Treatment Programs for Pervasive Developmental Disorders (PDD). Updated 07/10/2008.
23. ECRI Hotline Response: Non-drug Treatments for Pediatric Pervasive Developmental Disorders (PDD). Updated 06/15/05.
24. Shea V. A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism. 2004 Dec;8(4):349-67.
25. Magellan Health Services. Applied Behavioral Analysis (ABA) in the Treatment of Pervasive Developmental Disorder (PDD)/ Autism. Technology Assessment. Revised: June 27, 2008.
26. ECRI Institute. Health Technology Assessment Information Service (HTAIS). Custom Hotline Response: Applied Behavioral Analysis for Pervasive Developmental Disorders. Updated 05/23/2007.
27. National Institute of Mental Health. Autism Spectrum Disorders (Pervasive Developmental Disorders). 2007. [Available at http://www.nimh.nih.gov/health/publications/autism/complete-publication.shtml (last accessed 09/17/2007).]
28. Aman MG. Treatment Planning for Patients With Autism Spectrum Disorders. J Clin Psychiatry 2005;66[Suppl 10]:38-45.
29. New Jersey Autism and Developmental Disabilities mandate. # A2338. Effective 02/08/21010.
30. ECRI Institute Health Technology Assessment Information Service. Evidence Report: Comprehensive Educational and Behavioral Interventions for Autism Spectrum Disorders. Issue No. 167, February 2009.
31. Blue Cross Blue Shield Association Technology Evaluation Center (Tec). Special Report: Early Intensive Behavioral Intervention Based on Applied Behavioral Analysis among Children with Autism Spectrum Disorders. Assessment Program Volume 25, No. 9, February 2009.
32. AHRQ Comparative Effectiveness Review Number 26: Therapies for Children with Autism Spectrum Disorders - Executive Summary. AHRQ Pub. No. 11-EHC029-1, April 2011. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/106/651/Autism_Disorder_exec-summ.pdf
33. Warren Z, Veenstra-VanderWeele J, Stone W et al. Therapies for Children With Autism Spectrum Disorders, Comparative Effectiveness Review No. 26 (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I) AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2011. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/106/656/CER26_Autism_Report_04-14-2011.pdf
34. ECRI Institute. Health Technology Assessment Information Service (HTAIS). Evidence Report: Comprehensive Educational and Behavioral Interventions for Autism Spectrum Disorders. October 2011. Issue No, 189.
35. Maglione MA, Gans D, Das L et al. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012 Nov;130 Suppl 2:S169-78.
36. Magellan Health Services. Introduction to Magellan's Adopted Clinical Practice Guidelines for the Treatment of Children with Autism Spectrum Disorders. 2008-2012. Available at: http://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/clin_prac_guidelines/austism.pdf
37. Magellan Health Services. Applied Behavior Analysis (ABA) Treatments used in Autistic Spectrum Disorders (ASD). Technology Assessment. Revised: September 18, 2012.
38. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009260. DOI:10.1002/14651858.CD009260.pub2. Avalable at: http://www.uconnucedd.org/pdfs/Reichow2.pdf
39. Lounds Taylor J, Dove D, Veenstra-VanderWeele J et al. Interventions for Adolescents and Young Adults With Autism Spectrum Disorders. Comparative Effectiveness Review No. 65. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No. 12-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
40. UpToDate. Autism spectrum disorder in children and adolescents: Overview of management. Literature review current through: Dec 2016; topic last updated: Jun 24, 2016.
41. UpToDate. Autism spectrum disorder in children and adolescents: Behavioral and educational interventions. Literature review current through: Jan 2017; topic last updated: Nov 21, 2016.
42. American Psychiatric Society (APA) statement on Autism Spectrum Disorder DSM-V changes
43. Weissman L, Bridgemohan C. Autism spectrum disorder in children and adolescents: Behavioral and educational interventions. Torchia MM (ed). UpToDate, Waltham, MA. (Accessed on January 04, 2018.)
44. Weissman L, Bridgemohan C. Autism spectrum disorder in children and adolescents: Behavioral and educational interventions. Augustin M, Patterson MC, Torchia MM (ed). UpToDate, Waltham, MA. (Accessed on January 04, 2019.)
45. Weissman L.. Autism spectrum disorder in children and adolescents: Behavioral and educational interventions. Augustyn M, Patterson MC, Torchia MM (ed). UpToDate, Waltham, MA. (Accessed on January 06, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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