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.

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If not specified in a QualChoice coverage policy (Benefit Interpretation), 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: 01/01/2006 Title: Childhood Attention Deficit / Hyperactivity Disorder Treatment (ADHD)
Revision Date: 11/01/2018 Document: BI156:00
CPT Code(s): None
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.

Vyvanse, Guanfacine ER, and Daytrana require prior authorization QualChoice covers a range of other established treatments for childhood ADHD without requiring prior authorization. Childhood ADHD is defined as being in a person aged 20 or younger.


Medical Statement

1)    Childhood ADHD is defined as being in a person aged 20 or younger.

2)    The following drugs (both immediate-release and extended-release preparations) will be covered for the treatment of childhood ADHD without preauthorization (co-payments for generic medicines are typically less than for brand name formulations):

a)    Amphetamine

b)    Dextroamphetamine

c)    Oral methylphenidate

d)    atomoxetine

e)    Brand name formulations of the above medications subject to pharmacy plan rules related to those brand name agents.

3)    The following drugs will be covered for the treatment of ADHD only with preauthorization:

a)    Transdermal methylphenidate (Daytrana patch)

b)    Vyvanse (Lisdexamfetamine) – must demonstrate an unsuccessful trial of generic oral stimulant medications (including both methylphenidate and amphetamine products)

c)    Guanfacine ER

4)    Stimulants are considered first-line therapy for ADHD treatment.  As such, Guanfacine ER will require pre-authorization to demonstrate a previous unsuccessful trial of oral stimulant medications (both methylphenidate and amphetamine products).  Additionally, a history of substance abuse would also favor the use of guanfacine ER.

5)    Transdermal methylphenidate (Daytrana) has not been shown to be more effective than oral methylphenidate.  As such, Daytrana will require pre-authorization.  Criteria for approval would include demonstration that the member possesses an inability to swallow oral dosage forms or has extreme difficulty in swallowing oral dosage forms based on previous trial of oral stimulant medication.  Additional criteria allowing approval would be a demonstrated inability to tolerate the changes in blood level of drug attendant even on the use of long-acting preparations.


Limits

1)    Neuropsychological testing is not considered medically necessary for the clinical evaluation of persons with uncomplicated cases of ADHD.

2)    Psychological testing is not considered medically necessary for evaluation of children with uncomplicated cases of ADHD.

3)    Per the American Academy of Pediatrics (2000) the following have no proven value in the diagnosis and evaluation of patients with ADHD and therefore are not covered:

a)    Routine screening of thyroid function as part of the effort to diagnose ADHD.

b)    Any available continuous performance tests in the diagnosis of ADHD

c)    Current literature does not support the routine use of EEG in the diagnosis of ADHD.

d)    Neuroimaging studies should not be used as a screening or diagnostic tool for children with ADHD because they are associated with high rates of false-positives and false-negatives.

e)    Regular screening of children for high lead levels does not aid in the diagnosis of ADHD.

4)    QualChoice considers following Experimental and Investigational;

a)    Diagnosis:

i)     Actometer/Actigraph (see CPB 0710 - Actigraphy and Accelerometry)

ii)    AFF2 gene testing

iii)   Computerized EEG (brain mapping or neurometrics (see CPB 0221 - Quantitative EEG (Brain Mapping))

iv)   Computerized tests of attention and vigilance (continuous performance tests) (eg, Gordon Diagnostic System)

v)    Education and achievement testingFootnotes*

vi)   EEG theta/beta power ratio for the diagnosis of attention deficit hyperactivity disorder

vii) Electronystagmography (in the absence of symptoms of vertigo or balance dysfunction)

viii)        Evaluation of iron status (e.g., measurement of serum iron and ferritin levels)

ix)   Event-related potentials (see CPB 0181 - Evoked Potential Studies)

x)    Functional near-infrared spectroscopy (fNIRS)

xi)   Hair analysis (see CPB 0300 - Hair Analysis)

xii) IgG blood tests (for prescription of diet)

xiii)         Measurements of peripheral brain-derived neurotrophic factor

xiv)        Measurements of serum lipid patterns

xv) Measurement of zinc

xvi)        Neuroimaging (e.g., CT, CAT, MRI [including diffusion tensor imaging], magnetic resonance spectroscopy (MRS), PET and SPECT)

xvii)       Neuropsychiatric EEG-based assessment aid (NEBA) System

xviii)     Otoacoustic emissions (in the absence of signs of hearing loss)

xix)        Pharmacogenetic testing of drug response

xx) Quotient ADHD system/test

xxi)        SNAP25 gene polymorphisms testing

xxii)       Transcranial magnetic stimulation-evoked measures (e.g., short interval cortical inhibition in motor cortex) as a marker of ADHD symptoms

xxiii)     Tympanometry (in the absence of hearing loss)

 

b)    Treatment:

-       Acupuncture

-       Anti-candida albicans medication

-       Anti-fungal medications

-       Anti-motion-sickness medication

-       Applied kinesiology

-       Brain integration therapy

-       Chelation

-       Chiropractic manipulation

-       Cognitive behavior modification (cognitive rehabilitation)

-       Computerized training on working memory (e.g., Cogmed and RoboMemo)Footnotes*

-       Deep pressure sensory vest

-       Dietary counseling and treatments (ie Feingold diet)

-       Dore program/dyslexia-dyspraxia attention treatment (DDAT)

-       Educational intervention (e.g., classroom environmental manipulation, academic skills training, and parental training)Footnotes*

-       EEG biofeedback, also known as neurofeedback (see CPB 0132 - Biofeedback)

-       Intensive behavioral intervention programs (e.g., applied behavior analysis [ABA], early intensive behavior intervention [EIBI], intensive behavior intervention [IBI], and Lovaas therapy)

-       Megavitamin therapy Metronome training (see CPB 0325 - Physical Therapy Services)

-       Mineral supplementation (e.g., iron, magnesium and zinc)

-       Herbal remedies (e.g., Bach flower)

-       Reboxetine

-       Homeopathy

-       Neurofeedback (EEG biofeedback)

-       Optometric vision training/Irlen lenses

-       Psychopharmaceuticals: lithium, benzodiazepines, and selective serotonin re-uptake inhibitors

-       Sensory (auditory) integration therapy Syntonic phototherapy

-       Music therapy (see CPB 0388 - Complementary and Alternative Medicine)

-       The Good Vibrations device Footnotes*

-       The Neuro-Emotional Technique

-       Therapeutic eurythmy (movement therapy)

-       Transcranial magnetic stimulation/cranial electrical stimulation (see CPB 0469 - Transcranial Magnetic Stimulation and Cranial Electrical Stimulation)

-       Vayarin (phosphatidylserine-containing omega3 long-chain polyunsaturated fatty acids)

-       Vision therapy

-       Yoga (see CPB 0388 - Complementary and Alternative Medicine)


Background

1)    ADHD is the most common behavioral disorder in children, affecting as many as 4% to 12% of school aged children.

2)    The diagnosis of ADHD in children is a clinical diagnosis, based primarily on observations by parents and teachers, confirmed by clinician observation. Testing has no role in making the diagnosis, but may have a role in confirming the diagnosis or in assessing an affected individual for other problems affecting learning. In adults, the diagnosis of ADHD is dependent on a continuation of the condition from childhood. Mere distractibility or short attention span in an adult is not sufficient to support this diagnosis – other causes should be sought.

3)    Although it seems counter-intuitive that a stimulant should reduce hyperactivity and assist with the focusing and maintenance of attention, this is exactly what happens with treatment with stimulants. Dextroamphetamine was the first used in this group and remains effective, but it is subject to abuse (generally not by children with ADHD, but by their unaffected peers). The use of Dextroamphetamine has generally given way to the use of methylphenidate (Ritalin and others), which has been equally effective and appears to have less abuse potential.

4)    ADHD may continue into adulthood.

5)    Experience has shown that new medications are not always better than standard therapy, and may actually prove to be less beneficial and at times harmful when sufficient clinical experience is attained. With time, we may well discover that the newer agents are dramatically more effective or less risky in some or all of the affected population.


Reference

Addendum:

1)    Effective 02/01/2017: Added Vyvanse to policy requiring prior authorization.

2)    Effective 08/01/2017 Added Guanfacine ER to policy requiring prior authorization.


Application to Products
This policy applies to all health plans 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) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, 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.