The following services are covered benefits for the assessment of a member with suspected or known ASD:

• Medical evaluation (complete medical history and physical examination).
• behavioral health evaluation including psychiatric examination
• Parent and/or child interview (including siblings of children with autism).
• autism-specific developmental screening (Checklist for Autism in Toddlers [CHAT], Pervasive Developmental Disorder Screening Test-II) and Autism Behavior Checklist [ABC], Childhood Autism Rating Scale [CARS])
• occupational and/or physical therapy evaluation when motor deficits, motor planning or sensory dysfunction are present
• Evaluation by speech-language pathologist.
• Formal audiological hearing evaluation including frequency-specific brainstem auditory evoked response or otoacoustic emissions.
• Measurement of blood lead level if the child exhibits developmental delay and pica, or lives in a high-risk environment. Additional periodic lead screening can be considered if the pica persists.
• Genetic counseling for parents of a child with autism.
• Genetic testing - Refer to Medical Policy V.62 - Genetic Testing for Mulitsystem Inherited Disorders. 
• Quantitative plasma amino acid assays to detect phenylketonuria.
• Selective metabolic testing if the child exhibits any of the following:
1. Clinical and physical findings suggestive of a metabolic disorder (e.g., cyclic vomiting, early seizure, or lethargy); or
2. Dysmorphic or coarse features; or
3. Evidence of DD/ID; or
4. DD/ID can not be ruled out; or
5. Occurrence or adequacy of newborn screening for a birth defect is questionable.
• Electroencephalogram (EEG) for clinical spells that might represent seizures.

The following procedures and services may be Medically Necessary for the treatment of a member diagnosed with Autism Spectrum Disorder (ASD):

Behavioral health treatment (e.g., behavior modification, family therapy, or other forms of psychotherapy) that are clinically appropriate in terms of type, frequency, extent, site and duration, for the management of behavioral symptoms related to ASD may be Medically Necessary when required for the management of behaviors, especially where there is the potential for individuals to harm themselves or others, or when such treatment would otherwise be considered Medically Necessary. 

Intensive behavior interventions (e.g., early intensive behavior interventions [EIBI], intensive behavior intervention [IBI], Early Start Denver Model [ESDM], Lovaas therapy, applied behavior analysis [ABA] for any indication may be considered not medically necessary.

Some state mandate benefit coverage for applied behavioral analysis for treatment of ASD.  In those states, the applicable mandate must be followed.

Nebraska Revised Statutes, Chapter 44-7, 106 states:

44-7,106. Coverage for screening, diagnosis, and treatment of autism spectrum disorder; requirements.

Behavioral health treatment means counseling and treatment programs, including applied behavior analysis that are:  (i) Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; and (ii)  provided or supervised, either in person or by telehealth, by a behavior analyst certified by a national certifying organization or licensed psychologist, if services performed are within the boundaries of the psychologist’s competency. 

I.  An initial course of ABA treatment may be considered medically necessary for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met:

      A diagnosis of ASD has been made by a licensed medical professional or licensed psychologist AND the goals of intervention are appropriate for the individual's age and impairments with regards to type, frequency, intensity, extent, site and duration of services:

A.  Age 7 and under:  Social, communication, or language skills or adaptive functioning that have been identified as deficient relative to age expected norms, which forms the basis for an individual treatment plan. The treatment plan should include treatment with a certified or licensed ABA provider (in accordance with state law and benefit plan requirements) for 40 hours per week or less;  OR

B.  Age 8 and over:  Behaviors or deficits that are interfering with social, communication or language skills or adaptive functioning form the basis for an individualized treatment plan; The treatment plan should include treatment with a certified or licensed ABA provider (in accordance with state law and benefit plan requirements) for 40 hours per week or less; AND

2.  Documentation is provided which describes the individual-specific treatment plan that includes ALL of the following:

A.  Addresses the identified behavioral, psychological, family, and medical concerns; AND

B.  Has measurable goals in objective and measurable terms based on standardized assessments that address the behaviors and impairments for which the interventions are to be applied (NOTE: this should include, for each goal, baseline measurements, progress to date and anticipated timeline for achievement based on both the initial assessment and subsequent interim assessments over the duration of the interventions); AND

C.      Documents that ABA services will be delivered by an appropriate provider who is licensed or certified according to the requirements of applicable state laws and benefit plan requirements.

3.  Continuation of ABA treatment may be covered for an individual with ASD when a state mandate requires, or a benefit plan explicitly provides coverage for ABA when the current ABA treatment demonstrates significant improvement on treatment plan goals and progress toward bridging the member’s chronological and developmental age:

A.       The individual has met criteria for an initial course of ABA; AND

B.       The individual-specific treatment plan will be updated and submitted, in general, every 6 months or as required by a state mandate.   Note: treatment plans may be required more often than every 6 months when warranted by the individual circumstances; AND

C.       For each goal in the individual-specific treatment plan, the following is documented:

i. Significant improvement is: mastery of a minimum of 50 percent of stated goals and/or objectives found in the submitted treatment plan. This is demonstrated through pre- and post- data, including documented generalization of skills developed through goals across people, settings and environments.

ii. . Evidence used to show member progress toward bridging the gap between chronological and developmental ages include psychological tests. The documentation must show evidence of measurable functional improvement, as opposed to declining or plateaued scores.

iii. For members who do not master 50 percent of stated goals and objectives and/or demonstrate evidence toward bridging the gap between chronological and developmental ages, the treatment plan should clearly address the barriers to treatment success. Psychological testing may be requested to clarify lack of treatment response. If on subsequent reviews the member does not demonstrate significant improvement or progress mastering goals and objectives, and/or progress toward bridging the member’s chronological and developmental ages, coverage of ABA services may be denied through the peer review process.

4. Treatment is required for reasons other than the convenience of the patient, parents/caregiver/guardian, or physician or other health care provider.

5. Treatment is not a substitute for non-treatment services addressing environmental factors, nor primarily for custodial or respite care.

6.  ABA services are provided by a BCBA or line therapist supervised face to face by a BCBA/ AS, certified in Nebraska.  Supervision should be 2 hours per 10 hours of direct treatment.

7.  A comprehensive medical record is submitted by the ABA provider documenting the course of ABA treatment that includes all of the following documentation:

A. Initial assessment request with diagnostic evaluation

B. Individualized treatment plan with measurable goals and objectives that clearly addresses the active symptoms and signs of the member’s core deficits of ASD, formulated based on current assessments with reasonable expectations of mastery within a six-month period. The treatment plan should document these areas:

 i. Adaptive; for example, toilet training, dressing, joint attention skills, or eating

ii. Communication; for example, targets related to receptive and expressive communication and social language

 iii. Behavior; for example, reduction of problem behaviors such as operantly ruminating/vomiting, tantrum behavior, aggression, or self-injurious behavior

 iv. Social; for example, engaging in social play, engaging in appropriate eye contact, demonstrating setting-specific behaviors

 v. Collected data, including additional testing such as ABLLS, VB-MAPP or other developmentally appropriate assessments, celeration charts, graphs, progress notes that link to interventions of specific treatment plan goals/objectives

vi. Documentation of treatment participants and staff, procedures and setting

vii. Clinical documentation that the ABA therapy is focused on active symptoms of ASD that inhibit daily functioning and that gains made through treatment close the current gap with the member’s functioning level and same age peers

 viii.Transition and aftercare planning. Transition and aftercare planning should begin during the early phases of treatment. Planning should focus on the development of goals and treatments, as well as the identification of appropriate services and supports for the time-period following ABA treatment. The transition planning process and documentation should include active involvement and collaboration with a multidisciplinary team. Transition and aftercare goals must be developed specifically for the individual with ASD, be functional in nature, and focus on skills needed in current and future environments. Please refer to Guidelines for Treatment Record Documentation section of New Directions’ Provider Manual for rules on client file documentation.

Services provided in a daycare setting are an exclusion of the member’s contract and are excluded.  Services must be delivered in an office setting or through telehealth.

Note:  Parental participation is recommended for parent training to achieve desired outcomes, which may include but are not limited to reinforcement, task analysis, prompting, fading, shaping and chaining. 

Psycho-pharmacotherapy for management of target symptoms or co-morbidities related to ASM may be Medically Necessary

Note:  Coverage for pharmacotherapy is subject to the member’s specific benefits for drug coverage.  Please check benefit plan description

***For groups who do not fall under the Nebraska State Mandate BCBSNE has determined the following procedures and services  may bee considered not medically necessary as the peer-reviewed medical literature has been determined to be insufficient to find them to be Scientifically Validated in the assessment and treatment of ASD/PDD:

Assessment:

·         Allergy testing (including food allergy for gluten, casein, candida, and other molds; allergen specific IgG and IgE)

·         Electronystagmography (in the absence of dizziness, vertigo, or balance disorder)

·         Erythrocyte glutathione peroxidase studies

·         Event-related brain potentials

·         Hair analysis for trace elements

·         Intestinal permeability studies

·         Magnetoencephalography/magnetic source imaging

·         Neuroimaging studies such as CT, functional MRI (fMRI), MRI, MRS, PET, and SPECT

·         Nutritional testing (e.g., testing for arabinose and tartaric acid)

·         Provocative chelation tests for mercury

·         Stool analysis

·         Tests for celiac antibodies

·         Tests for homocysteine

·         Tests for immunologic or neurochemical abnormalities

·         Tests for micronutrients such as vitamin levels

·         Tests for mitochondrial disorders including lactate and pyruvate

·         Tests for thyroid function

·         Tests for urinary peptides

·         Tests for amino acids (except quantitative plasma amino acid assays to detect phenylketonuria), fatty acids (non-esterified), organic acids, citrate, silica, urine vanillylmandelic acid

·         Tests for heavy metals (e.g., antimony, arsenic, barium, beryllium, bismuth, mercury)

·         Tests for trace metals (e.g., aluminum, cadmium, chromium, copper, iron, lead, lithium, magnesium, manganese, nickel, selenium, zinc)

·         Tympanometry (in the absence of hearing loss).

Treatment:

·         Acupuncture

·         Anti-fungal medications (e.g., fluconazole, ketoconizole, metronidazole, nystatin)

·         Anti-viral medications (e.g., acyclovir, amantadine, famciclovir, isoprinosine, oseltamivir, valacyclovir)

·         Auditory integration training (auditory integration therapy)

·         Chelation Therapy

·         Cognitive rehabilitation

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

·         Facilitated communication

·         Herbal remedies (e.g., astragalus, berberis, echinacea, garlic, plant tannins, uva ursi)

·         Floor time therapy

·         Holding therapy

·         Immune globulin infusion

·         Manipulative therapies

·         Massage therapy

·         Music therapy and rhythmic entrainment interventions

·         Neurofeedback/EEG biofeedback

·         Nutritional supplements (e.g., dimethylglycine, glutathione, magnesium, megavitamins, omega-3 fatty acids, and high-dose pyridoxine)

·         Secretin infusion

·         Sensory integration therapy (see Medical Policy VII.49)

·         Stem cell transplantation

·         Systemic hyperbaric oxygen therapy

·         Tomatis sound therapy

·         Vision therapy

·         Vitamins and minerals (calcium, germanium, magnesium, manganese, selenium, tin, tungsten, vanadium, zinc, etc.).

·         Weighted blankets/vests.