Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    1) The treatment and diagnosis of Autism Spectrum Disorders are generally covered but many therapies require preauthorization and periodic re-evaluation (as with any therapy) to review the updated treatment plan, goals and documented benefits of interventions.  Preauthorization for further treatments will be based on the information provided in the periodic re-evaluation.

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2) For Applied Behavior Analysis, please see BI322.

1.    The diagnosis and treatment of Autism Spectrum Disorder (ASD) will be covered.  However, many therapies must be preauthorized and require periodic re-evaluation (as with any therapy) to review the updated treatment plan, goals and documented benefits of interventions.  Preauthorization for further treatments will be based on the information provided in the periodic re-evaluation.

2.    Definitions:

o   Autism Spectrum Disorder – Any of the pervasive developmental disorders as defined by the “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition”, including:

(A) Autistic Disorder

(B) Asperger’s Disorder and

(C) Pervasive Developmental Disorder, not otherwise specified.

o   Diagnosis – Medically necessary assessment, evaluations or tests to diagnose whether or not an individual has an Autism Spectrum Disorder (ASD).  Diagnostic evaluations do not need to be completed concurrently to diagnose Autism Spectrum Disorder (ASD).

o   Treatment –

(A) The following care prescribed, provided or ordered for a specific individual diagnosed with an Autism Spectrum Disorder (ASD) by a licensed physician or a licensed psychologist who determines the care to be medically necessary and evidence-based including without limitation:

(i)       Applied Behavior Analysis (see BI322);

(ii)      Pharmacy Care;

(iii)     Psychiatric care;

(iv)     Psychological care;

(v)      Therapeutic care; and

(vi)     Equipment determined necessary to provide evidence-based treatment

(B) Any care for an individual with Autism Spectrum Disorder (ASD) that is determined by a licensed physician to be:

(i)       Medically necessary; and

(ii)      Beneficial.

o   Applied Behavior Analysis – The design, implementation, and evaluation of environmental modifications by a board certified behavior analyst using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

3.    Coverage:

o   Cannot limit the number of visits an individual may make to an autism services provider.  However, despite no limit on the number of visits, many therapies must be preauthorized and require periodic re-evaluation (as with any therapy) review the updated treatment plan, goals and documented benefits of interventions.  Preauthorization for further treatments will be based on the information provided in the periodic re-evaluation.

o   Will be subject to other general exclusions and limitations, including without limitation:

                                 (A)  Coordination of benefits

                                 (B)  Participating provider requirements

                                 (C)  Restrictions on services provided by family or household members

                                 (D)  Utilization review of health care services including review of medical necessity, case management, and other managed care provisions.

o   For treatment under this section shall not be denied on the basis that the treatment is habilitative in nature.

o   For coverage on Applied Behavior Analysis, please see BI322.

Codes Used In This BI:

The following treatments or therapies are considered investigational and not medically necessary for the treatment of autism, Asperger`s syndrome, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (NOS):

a)    Chelation therapy

b)    Cognitive rehabilitation

c)    Elimination diets (e.g., gluten and milk elimination)

d)    Facilitated communication

e)    Immune globulin infusion

f)     Hyperbaric oxygen therapy

g)    Nutritional supplements (e.g., megavitamins, high-dose pyridoxine and magnesium, dimethylglycine)

h)    Pet therapy (e.g., Hippotherapy)

i)     Secretin infusion

j)     Spinal manipulation

k)    Vision therapy

l)     Electroconvulsive therapy

Arkansas Act 196 of 2011

Addendum: 

1.    Effective 04/01/2017: Updated with periodic re-evaluation requirement in order to preauthorize continued treatment and ensure benefit from interventions. 

Updated Claim Statement & Codes Used in This BI section to reflect new/deleted CPT codes. The following codes were deleted 1/1/17: 97001 – 97004. These codes were replaced with the following new codes effective 1/1/17: 97161 – 97168.

2.    Effective 1/1/2018: 2018 Code Updates. Updated Claim Statement & Codes Used in This BI section to reflect new/deleted CPT codes. The following code was deleted 1/1/18: 97532. This code was replaced with the following new code effective 1/1/18: 97127.

3.    Effective 01/01/2020:  2020 Code Updates – Code 97127 deleted and replaced by codes 97129 and 97130.

4.    Effective 03/01/2021: Electroconvulsive therapy (90870) is considered E/I for Autism Spectrum Disorder.

This policy applies to all group health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.