Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2007 Title: Autism Spectrum Disorder Treatment
Revision Date: 01/01/2018 Document: BI184:00
CPT Code(s): 90283, 90832-90834, 90836-90840, 90847, 90863, 90870, 92507, 97001-97004, 97112, 97113, 97116, 97124, 97127, 97139, 97161-97168, 97127, 97139, 97530, 97533, 97535, 98925-98929, 98940-98942, 99183, G0277, J0470, J0600, J0895, J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1599, J2850, J3520, M0300, S8940, S9338, S9355
Public Statement

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.

.

2) For Applied Behavior Analysis, please see BI322.


Medical Statement

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:

ACTIVE

90283

Immune globulin (IgIV), human, IV use

90832

Psychotherapy, 30 mn w/pt &/or family mbr

90833

            when perf w/E&M svc

90834

Psychotherapy, 45 min w/pt &/or family mbr

90836

            when perf w/E&M svc

90837

Psychotherapy, 60 min w/pt &/or family mbr

90838

            when perf w/E&M svc

90839

Psychotherapy for crisis; first 60 min

90840

            ea addtl 30 mn

90847

Family psychotherapy w/pt present

90863

Pharm mgmt, incl rx & rvw of meds, when perf w/psychotherapy svcs

90870

Electroconvulsive therapy

92507

Trtmt of speech, lang, voice, commun, &/or auditory proc disordr; indiv

97161

PT Evaluation: low complexity

97162

PT Evaluation: med complexity

97163

PT Evaluation: high complexity

97164

PT Re-evaluation

97165

OT Evaluation: low complexity

97166

OT Evaluation: med complexity

97167

OT Evaluation: med complexity

97168

OT Re-evaluation

97112

Therapeutic proc, 1+ areas, ea 15 mn; neuromusc re-ed of mvmt, balance, coord, kinesthetic sense, posture, &/or proprioception for sitting &/or standing activities

97113

Aquatic therapy w/therapeutic exercises

97116

Gait training (incl stair climbing)

97124

Massage, incl effleurage, petrissage &/or tapotement

97127

Therapeutic interventions that focus on cogn fnctn & compensatory strategies to manage perform of an activity, dir pt cntct (new code 1/1/18)

97139

Unlisted therapeutic proc

97530

Therapeutic activities, dir pt contact, ea 15 mn

97533

Sensory intgrtv technq to enhance snsry prcsng & promote adaptive resp to envrnmntl demands, dir pt cntct, ea 15 mn

97535

Self-care/home mgmt training, dir pt contact, ea 15 mn

98925

Osteopathic manip trtmt (OMT); 1-2 body regions involved

98926

          3-4  body regions involved

98927

          5-6  body regions involved

98928

          7-8  body regions involved

98929

          9-10  body regions involved

98940

Chiropractic manip trtmt (CMT); spinal, 1-2 regions

98941

          spinal, 3-4 regions

98942

          spinal, 5 regions

99183

Physician attendance & supv of hyperbaric oxygen therapy; per session

G0277

Hyperbaric oxygen under pressure, full body chamber, per 30 mn interval

J0470

Dimercaprol Inj, per 100 mg (BAL in oil).

J0600

Edetate calcium disodium Inj, up to 1,000 mg

J0895

Deferoxamine mesylate Inj, 500 mg (Desferal)

J1459

Immune globulin Inj (Privigen), IV, non-lyophilized, 500 mg

J1557

Immune globulin Inj (Gammaplex), IV, non-lyophilized, 500 mg

J1561

Immune globulin Inj (Gamunex), IV, non-lyophilized, 500 mg

J1566

Immune globulin Inj , IV, lyophilized, NOS, 500 mg

J1568

Immune globulin Inj (Octagam), IV, non-lyophilized, 500 mg

J1569

Immune globulin Inj (Gammagard liquid), IV, non-lyophilized 500 mg

J1572

Immune globulin Inj (Flebogamma/Flebogamma DIF), IV, non-lyophilized; 500 mg

J1599

Inj, immune globulin, IV, non-lyophilized, NOS, 500 mg

J2850

Inj, secretin, synthetic, human, 1 microgram

J3520

Edetate disodium, per 150 mg

M0300

IV chelation therapy

S8940

Equestrian/hippotherapy, per session

S9338

Home infusn tx, immunotherapy, admin svcs, prof rx svcs, care coord & all necess suppl/equip, per diem

S9355

Home infusn tx, chelation therapy, admin svcs, care coord & all necess supp/eqpt, per diem

DELETED

97001

PT Evaluation (code deleted 1/1/17)

97002

PT Re-evaluation (code deleted 1/1/17)

97003

OT Evaluation (code deleted 1/1/17)

97004

OT Re-evaluation (code deleted  1/1/17)

97532

Dvlpmnt of cognitive skills to imprv attention, memory, prob solv, dir pt cntct, ea 15 mn (code deleted 1/1/18)


Limits

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


Reference

Arkansas Act 196 of 2011


Application to Products

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.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.