Medical Policy


Subject:Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
Policy #:  MED.00107Current Effective Date:  10/14/2014
Status:ReviewedLast Review Date:  08/14/2014

Description/Scope

This document addresses pharmacotherapeutic, medical, and clinical rehabilitative treatments and therapies used to treat Autism Spectrum Disorders (ASDs) and Rett syndrome. Behavioral health interventions, such as psychological and psychiatric therapies are not addressed in this document.

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: Please see the following related documents for additional information related to ASDs:

Position Statement

Medically Necessary:

Speech therapy interventions to improve verbal and nonverbal communication skills for individuals with Autism Spectrum Disorders and Rett syndrome are considered medically necessary when criteria for speech therapy are met.

Physical and occupational therapy for comorbid physical impairments for individuals with Autism Spectrum Disorders and Rett syndrome are considered medically necessary when criteria for physical and occupational therapy are met.  

Medical therapy, as indicated for comorbid medical conditions for individuals with Autism Spectrum Disorders and Rett syndrome is considered medically necessary when such treatment would otherwise be 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:

  1. Chelation therapy; and
  2. Cognitive rehabilitation; and
  3. Elimination diets (e.g., gluten and milk elimination); and
  4. Facilitated communication; and
  5. Immune globulin infusion; and
  6. Hyperbaric oxygen therapy; and
  7. Nutritional supplements (e.g., megavitamins, high-dose pyridoxine and magnesium, dimethylglycine); and
  8. Pet therapy (e.g., Hippotherapy); and
  9. Secretin infusion; and
  10. Spinal manipulation; and
  11. Vision therapy.
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 both ASD and Rett syndrome.  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.  There is a wide array of medical, pharmacological, and other treatments proposed for the treatment of ASDs.  For the vast majority of these treatment methods, there is a lack of scientific evidence regarding their effectiveness, safety, relevance, and/or reliability in improving the pathological manifestations of ASDs.  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 disorders 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 (2014) indicates that the incidence of ASD was as high as 1 in 68. 

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 or more aspects of the condition being treated.  There is no single treatment that has consistently demonstrated benefit at the core symptoms of these disorders.  Treatments/interventions (such as speech and language therapy) are of greatest potential benefit in the pre-school child, and of very limited value in the older child/adolescent, so that the age of the child is also a factor in determining the appropriateness and necessity of a given treatment.  Medications can play a role in the management of some behavioral symptoms of autism spectrum disorder.  For example, risperidone and aripiprazole are FDA approved for the treatment of irritability. 

A wide variety of medical, pharmacological and other treatments have been proposed for the treatment of ASDs.  Unfortunately for the vast majority of them there is a lack of scientific evidence demonstrating any significant health or behavioral benefits.

Definitions

Asperger's syndrome: A developmental disorder that affects the parts of the brain that control social interaction and communications. Asperger's is no longer considered a separate condition, but is now considered within the ASD group of conditions based upon the DSM-5 criteria.

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.

Childhood disintegrative disorder (CDD):  A developmental disorder characterized by marked regression in multiple areas of functioning following a period of at least 2 years of apparently normal development. CDD is no longer considered a separate condition, but is now considered within the ASD group of conditions based upon the DSM-5 criteria.

Cognitive rehabilitation: A proposed treatment for autism spectrum disorders involving psychological therapy.

Educational Interventions: Learning interventions that assist children with obtaining knowledge, communication through speech, sign language, writing and other methods and social skills (NOTE: Many benefit contracts exclude coverage for services that are educational in nature).

Elimination diets: A proposed treatment for autism spectrum disorders involving specialized diets that omit specific foods or food groups such as gluten and milk.

Facilitated communication: A method of communication using aids or alternatives to speech such as sign language, flashcards, communication boards, etc.

Immune globulin infusion: A proposed treatment for autism spectrum disorders involving the injection/infusion of immune substances known as immune globulins into the body.

Music therapy and rhythmic entrainment interventions: A proposed treatment for autism spectrum disorders involving the use of music or rhythmic sounds such as from drums.

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

Secretin infusion: A proposed treatment to pervasive developmental delay syndromes involving the injection/infusion of the hormone secretin into the body.

Vision therapy: A proposed treatment for autism spectrum disorders that involves focusing an individual's attention on a single visual stimuli in an attempt to improve their attention span and ability to mentally focus their attention.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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:
92507-92508Treatment of speech, language, voice, communication, and/or auditory processing disorder [includes codes 92507, 92508]
92521Evaluation of speech fluency (eg, stuttering, cluttering)
92522Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria);
92523Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524Behavioral and qualitative analysis of voice and resonance
  
HCPCS 
S9152Speech therapy, re-evaluation
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
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 Diagnosis[For dates of service on or after 10/01/2015]
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.

CPT 
90283Immune globulin (IgIV), human, for intravenous use
97532Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
98925-98929Osteopathic manipulative treatment (OMT) [includes codes 98925, 98926, 98927, 98928, 98929, when specified as manipulation of spinal regions]
98940-98942Chiropractic manipulative treatment (CMT); spinal [includes codes 98940, 98941, 98942]
99183Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy; per session
  
HCPCS 
C1300Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
E1399Durable medical equipment, miscellaneous [when specified as facilitated communication devices]
J0470Injection, dimercaprol, per 100 mg (BAL in oil)
J0600Injection, edetate calcium disodium up to 1,000 mg
J0895Injection, deferoxamine mesylate, 500 mg (Desferal)
J1459Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg
J1556Injection, immune globulin (Bivigam), 500 mg
J1557Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg
J1561Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g., liquid), 500 mg
J1566Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg
J1568Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg
J1569Injection, immune globulin, (Gammagard liquid), non-lyophilized (e.g., liquid), 500 mg
J1572Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g., liquid); 500 mg
J1599Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg
J2850Injection, secretin, synthetic, human, 1 microgram
J3520Edetate disodium, per 150 mg
M0300IV chelation therapy
S8940Equestrian/hippotherapy, per session
S9338Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9355Home infusion therapy, chelation therapy; administrative services, care coordination, and all necessary supplies and equipment, per diem
  
ICD-9 Procedure[For dates of service prior to 10/01/2015]
93.95Hyperbaric oxygenation
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
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 Procedure[For dates of service on or after 10/01/2015]
5A05121Extracorporeal hyperbaric oxygenation, intermittent
5A05221Extracorporeal hyperbaric oxygenation, continuous
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
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. Gutstein, SE, Burgess AF, Montfort K.  Evaluation of the relationship development intervention program.  Autism. 2007; 11(5):397-411.
  3. Howard JS, Sparkman CR, Cohen HG, et al. A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Res Dev Disabil. 2005; 26(4):359-383.
  4. Rossignol DA.  Hyperbaric oxygen therapy might improve certain pathophysiological findings in autism. Med Hypotheses. 2007a; 68(6):1208-1227.
  5. Rossignol DA, Rossignol LW, James SJ, et al. The effects of hyperbaric oxygen therapy on oxidative stress, inflammation, and symptoms in children with autism: an open-label pilot study. BMC Pediatr. 2007b; 7(1):36.
  6. Rossignol DA, Rossignol LW, Smith S, et al. Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind, controlled trial. BMC Pediatr. 2009; 13(9):21.
  7. 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. 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 June 17, 2014.
  2. 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.
  3. 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.
  4. Canadian Pediatric Society Position Statement. Early intervention for children with autism. Pediatr Child Health. 2004; 9(4):267-277.
  5. Centers for Disease Control and Prevention. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010. Morbidity and Mortality Weekly Report (MMWR). 2014; 3(SS02);1-21.  Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm?s_cid=ss6302a1_w. Accessed on June 16, 2014.   Centers for Medicare and Medicaid Services. National Coverage Determination for Manipulation. NCD #150.1 Effective date: N/A. Available at:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on June 17, 2014.
  6. Ching H, Pringsheim T. Aripiprazole for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;(5):CD009043.
  7. 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.
  8. Hurwitz R, Blackmore R, Hazell P, et al. Tricyclic antidepressants for autism spectrum disorders (ASD) in children and adolescents. Cochrane Database Syst Rev. 2012;(3):CD008372
  9. James S, Montgomery P, Williams K. Omega-3 fatty acids supplementation for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;(11):CD007992.
  10. Mahajan R, Bernal MP, Panzer R, et al.; Autism Speaks Autism Treatment Network Psychopharmacology Committee. Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism spectrum disorders. Pediatrics. 2012; 130(Suppl 2):S125-S138.
  11. Malow BA, Byars K, Johnson K, et al.; Sleep Committee of the Autism Treatment Network. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics. 2012; 130(Suppl 2):S106-S124.
  12. 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 June 17, 2014.
  13. New York State Department of Health Early Intervention Program. Clinical Practice Guideline Report of the Guideline Recommendations – Autism / Pervasive Developmental Disorders – Assessment and Intervention For Young Children (Age 0-3 Years).  Available at: http://www.health.state.ny.us/nysdoh/eip/autism/index.htm#Table_of_Contents. Accessed on June 17, 2014.
  14. Volkmar F, Siegel M, Woodbury-Smith M, et al.; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry, 2014; 53(2):237–257.
  15. Williams K, Brignell A, Randall M, et al. Selective serotonin reuptake inhibitors (SSRIs) for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2013;(8):CD004677.
  16. Williams K, Wray JA, Wheeler DM. Intravenous secretin for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;(4):CD003495.
Websites for Additional Information
  1. International Rett Syndrome Association. Avalable at: http://www.rettsyndrome.org. Accessed on June 16, 2014.
  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 June 16, 2014.
  3. National Institute of Neurological Disorders and Stroke. Pervasive Developmental Disorders Available at: http://www.ninds.nih.gov/disorders/pdd/pdd.htm.  Accessed on June 16, 2014.
  4. National Library of Medicine. Medical Encyclopedia, Autism. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm. Accessed on June 16, 2014.
  5. National Library of Medicine. Medical Encyclopedia, Rett Syndrome. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001536.htm. Accessed on June 16, 2014.
  6. The Nemours Foundation. Pervasive Developmental Disorders. Available at: http://kidshealth.org/parent/medical/learning/pervasive_develop_disorders.html. Accessed on June 16, 2014.
Index

Alternative Communication
Augmentative Communication Aids
Autism
Chelation Therapy
Discrete Trial Training
Globulin Infusion

Document History
StatusDateAction
Reviewed08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed08/08/2014Behavioral Health Subcommittee review.  No change to position statement. Updated Description/Scope, Rationale, and Reference sections. 
 01/01/2014Updated Coding section with 01/01/2014 CPT and HCPCS changes; removed 92506, C9130 deleted 12/31/2013.
Reviewed08/08/2013MPTAC review.
Reviewed07/26/2013Behavioral Health Subcommittee review.  Revised title and clinical indications sections to replace "Pervasive Developmental Disorders" with "Autism Spectrum Disorders".  Revised Description, Discussion, and Reference sections. 
 04/01/2013Updated Coding section with 04/01/2013 HCPCS changes.
 01/01/2013Updated Coding section with 01/01/2013 CPT and HCPCS descriptor changes.
Reviewed08/09/2012Medical Policy & Technology Assessment Committee review.  No change to position statement.
 04/01/2012Updated Coding section; HCPCS J1557 replaced C9270 effective 01/01/2012.
Reviewed08/18/2011Medical Policy & Technology Assessment Committee review.  No change to position statement.
 01/01/2011Updated Coding section with 01/01/2011 HCPCS changes.
New08/19/2010Medical Policy & Technology Assessment Committee review.  Initial document development.  Moved non-behavioral health treatments from BEH.00004 to new document.  Added spinal manipulation to Investigational and Not Medically Necessary section.  Updated Coding section to include 10/01/2010 HCPCS changes.