Medical Policy


Subject:Behavioral Health Treatments for Autism Spectrum Disorders and Rett Syndrome
Policy #:  BEH.00004Current Effective Date:  10/08/2013
Status:RevisedLast Review Date:  08/08/2013

Description/Scope

This document addresses pharmacotherapeutic and behavioral health-related treatments and therapies used to treat Autism Spectrum Disorders (ASDs) and Rett syndrome.  ASDs, as defined in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), include disorders previously referred to as:

Note: For information on other services that may be provided for Autism Spectrum Disorders, see

Note: This document does not address Applied Behavior Analysis or Applied Behavioral Analysis (ABA) therapy.  For more information regarding ABA and other Educational treatment methods, please see: 

Position Statement

Medically Necessary:

Behavior modification, family therapy, or other forms of psychotherapy, that are clinically appropriate in terms of type, frequency, extent, site and duration, for management of behavioral symptoms related to Autism Spectrum Disorders and Rett syndrome are considered 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.

Psycho-pharmacotherapy for management of target symptoms or co-morbidities related to Autism Spectrum Disorders and Rett syndrome, is considered medically necessary.    

Investigational and Not Medically Necessary: 

The following treatments or therapies are considered investigational and not medically necessary for the treatment of Autism Spectrum Disorders and Rett syndrome:

Rationale

ASDs and Rett syndrome are complex and multifaceted conditions for which there is no known specific etiology, although there is evidence of a genetic etiology in ASDs.  The impairments of these conditions are generally severe, and, given the uncertainty around the cause(s) of these disorders, treatments are not directed at the core pathology, but at the comorbid medical and behavioral conditions.  The above noted medically necessary treatments have validity as components of treating ASD-associated comorbidities, and are evidence-based.  Those treatments deemed Investigational and Not Medically Necessary lack sufficient evidence as to their effectiveness, safety, relevance, and/or reliability in improving the pathological manifestations of ASDs.

Background/Overview

In May 2013 the American Psychiatric Association (APA) released the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).  This edition of the DSM includes several significant changes over the previous edition, including combining several previously separate diagnoses under the single diagnosis of "autism spectrum disorder".  This diagnosis includes the following disorders, previously referred to as: atypical autism, Asperger's disorder, childhood autism, childhood disintegrative disorder, early infantile autism, high-functioning autism, Kanner's autism, and pervasive developmental disorder not otherwise specified.  All of these conditions are now considered under one diagnosis, ASD.  It should be noted that Rett is not included in the new DSM-5 ASD diagnostic group.

The DSM-5 describes the essential diagnostic features of autism spectrum disorder as both a persistent impairment in reciprocal social communication and restricted and repetitive pattern of behavior, interest or activities.  These attributes are present from early childhood and limit or impair everyday functioning.  Parents may note symptoms as early as infancy, and the typical age of onset is before 3 years of age.  Symptoms may include problems with using and understanding language; difficulty relating to or reciprocating with people, objects, and events; lack of mutual gaze or inability to attend events conjointly; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings, and repetitive body movements or behavior patterns.  Children with childhood disintegrative disorder are an exception to this description, in that they exhibit normal development for approximately 2 years followed by a marked regression in multiple areas of function.

Children with ASD vary widely in abilities, intelligence, and behaviors.  Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development.  Repetitive play skills, resistance to change in routine and inability to share experiences with others, and limited social and motor skills are generally evident.  Unusual responses to sensory information, such as loud noises and lights, are also common.  Children unaffected by ASDs can exhibit unusual behaviors occasionally or seem shy around others sometimes without having ASD.  What sets children with ASD apart is the consistency of their unusual behaviors.  Symptoms of the disorder have to be present in all settings, not just at home or at school, and over considerable periods of time.  With ASD, there is a lack of social interaction, impairment in nonverbal behaviors, and a failure to develop normal peer relations.  A child with an ASD tends to ignore facial expressions and may not look at others; other children may fail to respect interpersonal boundaries and come too close and stare fixedly at another person.

The exact causes of autism are unknown, although genetic factors are strongly implicated.  A study released by the Center for Disease Control and Prevention (2012) indicates that the incidence of ASD was as high as 1 in 88. 

Rett syndrome is a disorder of the nervous system that leads to regression in development, especially in the areas of expressive language and hand use.  In most cases, it is caused by a genetic mutation.  It occurs almost exclusively in girls and may be misdiagnosed as autism or cerebral palsy.

Seventy-five percent of Rett syndrome cases have been linked to a specific genetic mutation on the X chromosome.  This gene contains instructions for creating methyl-CpG-binding protein 2 (MeCP2), which regulates the manufacture of various other proteins.  Mutations in the MeCP2 gene cause these other proteins to be produced incorrectly, which damage the maturing brain.  Studies link mutations in this gene.  Most cases of the mutation arise spontaneously without any traceable cause.  However, there also seem to be some clusters within families and certain geographic regions, for example Norway, Sweden, and Northern Italy.

A child affected with Rett syndrome normally follows a standard developmental path for the first 5 months of life.  After that time development in communication skills and motor movement in the hands seems to stagnate or regress.  After a short period stereotyped hand movements, gait disturbances, and slowing of the rate of head growth become apparent.  Other problems may also be associated with Rett syndrome, including seizures, disorganized breathing patterns while awake and apraxia/dyspraxia (the inability to program the body to perform motor movements).  Apraxia/dyspraxia is a key symptom of Rett syndrome and it results in significant functional impairment, interfering with body movement, including eye gaze and speech.

The treatment of ASDs may take many different approaches, focusing on one of more aspects of the condition being treated.  There is no single treatment that has consistently demonstrated benefit at the core symptoms of these disorders.  Family therapy is generally supported as a valuable treatment because it offers emotional support and guidance to parents who will contend with a myriad of services to assist their child.  Individual therapy using social story technique and behavioral cue coaching are very useful for the older child/adolescent with Asperger's syndrome and can make a difference in that child's acceptance by others.

Definitions

Asperger's syndrome: A developmental disorder that affects the parts of the brain that control social interaction and communications.

Autism Spectrum Disorders: A collection of associated developmental disorders that affect the parts of the brain that control social interaction and verbal and non-verbal communication.

Behavior modification: A therapy type that is designed to create new behavior patterns in people through intensive and frequent feedback using a reward, non-reward system.

Childhood disintegrative disorder:  A developmental disorder characterized by marked regression in multiple areas of functioning following a period of at least 2 years of apparently normal development.

Rett syndrome: A developmental disorder that affects the parts of the brain that control social interaction, communications, and motor function.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

When services are Medically Necessary: 

CPT 
 Services may include, but are not limited to, the following:
90785Interactive complexity
90832-90838Psychotherapy services [includes codes 90832, 90833, 90834, 90836, 90837, 90838]
90846-90853Family and group psychotherapy services [includes codes 90846, 90847, 90849, 90853]
90863Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services
  
HCPCS 
G0410Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes
G0411Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes
  
ICD-9 Diagnosis 
299.00-299.01Autistic disorder
299.10-299.11Childhood disintegrative disorder
299.80-299.81Other specified pervasive developmental disorders (Asperger's disorder)
299.90-299.91Unspecified pervasive developmental disorder
330.8Other specified cerebral degenerations in childhood (Rett's syndrome)
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
F84.0Autistic disorder
F84.2Rett's syndrome
F84.3Other childhood disintegrative disorder
F84.5Asperger's syndrome
F84.8Other pervasive developmental disorders
F84.9Pervasive developmental disorder, unspecified

When services are Investigational and Not Medically Necessary:
For the following procedure and diagnosis codes; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

HCPCS 
G0176Activity therapy, such as music, dance, art or play therapies, not for recreation, related to the care and treatment of patient's disabling mental health problems, per session
  
ICD-9 Diagnosis 
299.00-299.01Autistic disorder
299.10-299.11Childhood disintegrative disorder
299.80-299.81Other specified pervasive developmental disorders (Asperger's disorder)
299.90-299.91Unspecified pervasive developmental disorder
330.8Other specified cerebral degenerations in childhood (Rett's syndrome)
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
F84.0Autistic disorder
F84.2Rett's syndrome
F84.3Other childhood disintegrative disorder
F84.5Asperger's syndrome
F84.8Other pervasive developmental disorders
F84.9Pervasive developmental disorder, unspecified
  
References

Peer Reviewed Publications:

  1. Dawson G, Rogers S, Munson J, et al.  Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010; 125(1):e17-e23.
  2. Eldevik S, Eikeseth S, Jahr E, Smith T. Effects of low-intensity behavioral treatment for children with autism and mental retardation. J Autism Dev Disord. 2006; 36(2):211-224.
  3. Gutstein, SE, Burgess AF, Montfort K.  Evaluation of the relationship development intervention program.  Autism. 2007; 11(5):397-411.
  4. Howard JS, Sparkman CR, Cohen HG, et al. Comparison of intensive behavior analytic and eclectic treatments for young children with autism. Res Dev Disabil. 2005; 26(4):359-383.
  5. Sheinkopf SJ, Siegel B.  Home-based behavioral treatment of young children with autism. J Autism Dev Disord. 1998; 28(1):15-23.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. Academy of Child and Adolescent Psychiatry Working group on Quality Issues. J Am Acad Child Adolesc Psychiatry. 1999; 38(Supp 12):32S-54S.
  2. American Academy of Child and Adolescent Psychiatry. Policy Statement- Secretin in the Treatment of Autism. June 15, 2002. Available at: http://www.aacap.org/cs/root/policy_statements/secretin_in_the_treatment_of_autism. Accessed on May 29, 2013.
  3. American Academy of Pediatrics; Committee on Children with Disabilities. The pediatrician's role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics. 2001; 107(5):1221-1226.
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  DSM-5. Washington, DC.  May 2013.
  5. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators; Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders--autism and developmental disabilities monitoring network, 14 sites, United States, 2002. MMWR Surveill Summ. December 18, 2009; 58(SS10):1-20.
  6. Canadian Pediatric Society Position Statement, Early intervention for children with autism, published in Pediatric Child Health. 2004; 9(4):267-277.
  7. Centers for Disease Control and Prevention. Prevalence of Autism Spectrum Disorders — Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008.  March 20, 2012.  Available at: http://www.cdc.gov/mmwr/pdf/ss/ss6103.pdf.  Accessed on May 29, 2013.
  8. Greenspan SI, Brazelton TB, Cordero J, et al. Guidelines for early identification, screening, and clinical management of children with autism spectrum disorders.  Pediatrics. 2008; 121(4):828-830.
  9. Maglione MA, Gans D, Das L, et al.; Technical Expert Panel; HRSA Autism Intervention Research – Behavioral (AIR-B) Network. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012; 130(Suppl 2):S169-S478.
  10. McPheeters ML, Warren Z, Sathe N, et al. A systematic review of medical treatments for children with autism spectrum disorders. Pediatrics. 2011; 127(5):e1312-1321.
  11. Myer SM, Johnson CP, American Academy of Pediatrics Council on Children with Disabilities. Management of children with autism spectrum disorders. Pediatrics. 2007; 120(5):1162-1182.  Available at:  http://www.pediatrics.org/cgi/content/full/120/5/1162.  Accessed on May 29, 2013.
Web Sites for Additional Information
  1. International Rett Syndrome Association. Available at: http://www.rettsyndrome.org. Accessed on May 29, 2013.
  2. National Institute of Neurological Disorders and Stroke. Asperger's Syndrome - Short Summary. Available at: http://www.ninds.nih.gov/disorders/Asperger/Asperger.htm. Accessed on May 29, 2013.
  3. National Institute of Neurological Disorders and Stroke. Pervasive Developmental Disorders Available at: http://www.ninds.nih.gov/disorders/pdd/pdd.htm.  Accessed on May 29, 2013.
  4. National Library of Medicine. Medical Encyclopedia, Autism. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm. Accessed on May 29, 2013.
  5. National Library of Medicine. Medical Encyclopedia, Rett Syndrome. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001536.htm. Accessed on May 29, 2013.
  6. The Nemours Foundation. Pervasive Developmental Disorders. Available at: http://kidshealth.org/parent/medical/learning/pervasive_develop_disorders.html. Accessed on May 29, 2013.
Index

Discrete Trial Training
Pet therapy

Document History
StatusDateAction
Reviewed08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed07/26/2013Behavioral Health Subcommittee review.  Revised title and clinical indications sections to replace "Pervasive Developmental Disorders" with "Autism Spectrum Disorders".  Clarified Investigational and NMN statement regarding activity therapy.  Revised Description, Discussion, and Reference sections. 
 01/01/2013Updated Coding section with 01/01/2013 CPT changes; removed codes 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90857, 90862 deleted 12/31/2012.
Reviewed08/09/2012MPTAC review.
Reviewed08/03/2012Behavioral Health Subcommittee review.  No change to position statement.  Updated Reference section.  Updated Coding section; removed ICD-9 procedure codes (not applicable).
Reviewed08/18/2011Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed08/12/2011Behavioral Health Subcommittee review.  No change to position statement.  Updated Reference section.
Revised08/19/2010MPTAC review.  Simplified document title. Removed all non-behavioral health-related treatments from BEH.00004 and moved them to new document: MED.00107. Updated Rationale, Background, Coding and Definitions sections.
Reviewed05/13/2010MPTAC review.  No change to position statement.  Updated Coding and Reference sections.
Reviewed02/21/2009MPTAC review.  No change to position statement.  Updated Reference section.
 01/01/2009Updated Coding section with 01/01/2009 HCPCS changes; removed Q4097 deleted 12/31/2008.
Revised07/25/2008MPTAC review. Clarified position statements in the medically necessary section. Added use of hyperbaric oxygen therapy and chelation therapy to investigational and not medically necessary position statement. Deleted Lovaas therapy from investigational and not medically necessary position statement.  Updated Rationale, Coding, and Reference sections.    
 01/01/2008Updated Coding section with 01/01/2008 HCPCS changes; removed HCPCS J1567, Q4087, Q4088, Q4091, Q4092 deleted 12/31/2007.  The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary."  This change was approved at the November 29, 2007 MPTAC meeting.
Revised08/23/2007MPTAC review. Minor wording revision to position statement for "Interventions to improve verbal and nonverbal communication skills." Updated Reference section.
 07/01/2007Updated Coding section with 07/01/2007 HCPCS changes; removed HCPCS J1563, J1564, Q9941, Q9942, Q9943, Q9944 deleted 12/31/2005.
Revised09/14/2006MPTAC review. Revised rationale; updated references.
Reviewed03/23/2006MPTAC review.
New12/01/2005MPTAC initial document development.