Coverage Policy Manual
Policy #: 2011054
Category: Medicine
Initiated: July 2011
Last Review: September 2018
  Autism Spectrum Disorder, Other Interventions

Description:
Autism spectrum disorder (ASD) is a complex, pervasive developmental  disability characterized by variable social and communicative deficits with  repetitive, restricted behaviors and for many, significant cognitive impairment.  The Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision (DSM-IV-TR) specifies autistic disorder, pervasive developmental disorder---not otherwise specified (PDD-NOS), and Asperger’s syndrome as included under the diagnosis of ASD. The Center for Disease Control (CDC) estimates the prevalence of ASD as 1 out of every 110 children occurring in all ethnic, racial, and socioeconomic groups but 4-5 times more likely in boys than girls. A CDC report published in 2009, demonstrated that an average of 41% of ASD individuals met a definition of intellectual disability.
 
  
Related Policies:
 Early Behavioral Intervention (ABA) for ASD ( 2011053)
 Sensory integration (2003043)
 IVIG (1997113)
 HBO (1997008)
 Chelation therapy (1998110)
 Hippotherapy (2003050)
 Functional intracellular analysis (2010047)
 Cognitive rehabilitation (1997036)
 Allergy testing (1998041)
 Orthoptic Training for Treatment of Vision and Learning Disabilities (1998008)
 
There are no HCPCS/CPT codes that specifically describe services for Autism.
 

Policy/
Coverage:
Members with autism spectrum disorder (ASD) are subject to the same array of medical and behavioral conditions as all other members.  The ASD diagnosis does not impact the coverage for these conditions which is the same as it would be without the diagnosis of ASD, based upon terms and conditions of the member’s certificate.  For evaluation and treatment of these conditions, the non-ASD diagnosis should be listed as the primary diagnosis; ASD may be listed as a secondary diagnosis for that encounter without impacting coverage.
 
To the extent of benefit limitations and contract exclusions the following services are covered subject to the demonstration of medical necessity and evidence of efficacy:
  • Psychiatric or psychological services
  • Medications
  • Speech therapy
  • Physical therapy
  • Occupational therapy
  
 
The following modalities do not meet primary coverage criteria that there is scientific evidence of effectiveness in improving health outcomes and are therefore not covered:
  • Secretin therapy
  • Facilitated communication
  • Nutritional or dietary supplements
  • Music therapy
  • Squeeze machine therapy
  • Craniosacral therapy (effective April 2012)
 
Guidelines:
Evidence of effectiveness  are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
• in accordance with generally accepted standards of medical practice; and
• clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and
• not primarily for the convenience of the patient, physician or other health care provider; and
• not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
 
For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.
 

Rationale:
Secretin is a gastrointestinal hormone that inhibits intestinal motility and release of gastric acid while stimulating the release of bicarbonate and pancreatic enzymes. The hypothesis that secretin might be of use in the treatment of ASD came largely from the observation that some children with ASD exhibited gastrointestinal symptoms.  More than 12 randomized controlled trials have demonstrated no benefit in the treatment of ASD.
 
Facilitated communication is a technique that utilizes a trained facilitator to provide physical support to a nonverbal person’s arm or hand while that person uses a computer keyboard or other device to write. Reviews of published studies have found no evidence to support its use and suggest that the communications produced actually originate from the facilitator; facilitated communication is not a valid treatment for ASD.
 
A number of differing nutritional supplements and dietary supplements have been proposed as treatments for ASD. The use of a gluten-free and/or casein-free diet is based on the supposition of abnormal gut permeability and exogenous opiate excess resulting in abnormal behaviors associated with ASD.  To date, Several larger scale, randomized controlled trials have failed to demonstrate any meaningful benefit. For those that chose to follow such a dietary plan, concerns about reduced bone mass and possible essential amino acid deficiencies have been expressed.  Trials of omega-3 fatty acids, B6 and magnesium, dimethylglycine, and probiotics have either demonstrated no clinical benefit or insufficient evidence of effectiveness.
 
Music therapy has been proposed for ASD treatment under the hypothesis that music could be an aid in the development of communication and social skills.  There is insufficient data to recommend this therapy.
 
2012 Update
A Best Evidence Statement was published by Cincinnati Children’s Hospital Medical Center (Cincinnati Children’s Hospital Medical Center, 2012). The statement indicates that there is insufficient evidence to make a recommendation on the use of craniosacral therapy in the treatment of children with autism and sensory processing disorder. There is a lack of scientific evidence that this therapy improves health outcomes in children with autism.
 
A search of ClinicalTrials.gov did not reveal any ongoing clinical trials assessing craniosacral therapy in the treatment of autism.
 
2013 Update
A literature search conducted through March 2013 did not reveal any new information that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted using the MEDLINE database did not reveal any new literature that would prompt a change in the coverage statement.   
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2018. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
92605Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
92606Therapeutic service(s) for the use of non-speech-generating device, including programming and modification
92607Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
92609Therapeutic services for the use of speech-generating device, including programming and modification
J2850Injection, secretin, synthetic, human, 1 mcg

References: American Academy of Pediatrics, Committee on Children With Disabilities.(1998) Auditory Integration Training and Facilitated Communication for Autism. Pediatrics. 1998;102:431-433.

Bent S, et al.(2009) Omega-3 fatty acids for autism spectrum disorder: a systematic review. J Autism Dev Disord. 2009; 39:1145.

Bolman WM, Richmond JA.(1999) A double-blind, placebo-controlled, crossover pilot trial of low dose dimethyglycine in patients with autistic disorder. J Autims Dev Disord 1999; 29:191.

Cincinnati Children's Hospital Medical Center.(2012) Best evidence statement (BESt). Craniosacral therapy for children with autism and/or sensory processing disorder. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Aug 25. 5 p.

Fernell E, Hedvall Å, Westerlund J, et al.(2011) Early intervention in 208 Swedish preschoolers with autism spectrum disorder. A prospective naturalistic study. Res Dev Disabil. 2011 Nov-Dec;32(6):2092-101.

Freitag CM, Feineis-Matthews S, Valerian J, Teufel K, Wilker C.(2012) The Frankfurt early intervention program FFIP for preschool aged children with autism spectrum disorder: a pilot study. J Neural Transm. 2012 Sep;119(9):1011-21.

Goods KS, Ishijima E, Chang YC, Kasari C.(2013) Preschool Based JASPER Intervention in Minimally Verbal Children with Autism: Pilot RCT. J Autism Dev Disord. 2013 May;43(5):1050-6.

Hediger ML, et al.(2008) Reduced bone cortical thickness in boys with autism spectrum disorder. Dev Disord 2008; 38:848.

Hyman S, et al.(2010) The gluten free and casein free diet: a double-blind, placebo-controlled challenge study. International Meeting for Autism Research (IMFAR). http://imfar.confex.com/imfar/2010/webprogram/Paper6183.html.

Jacobson JW, et al.(1995) A history of facilitated communication: science, pseudoscience, and antiscience. Science working group on Facilitated Communication. Am Psychol. 1995;50:750-765.

Nye C, Brice A.(2005) Combined vitamin B6-magnesium treatment in autism spectrum disorder. Cochrane Database Syst Rev. 2005:CD003497.

Reichow B, Barton EE, Boyd BA, Hume K.(2012) Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012 Oct 17;10.

Smith MD, et al.(1994) Facilitated Communication: the effects of facilitator knowledge and level of assistance on output. J. Autism Dev Disord. 1994;24:357-367.

Whitely P, et al.(2010) The ScanBrit randomized, controlled, sigle-blind study of gluten- and casein-free dietary intervention for children with autism spectrum disorder. Nutr Neurosci 2010; 13:87.

Williams KW, et al.(2005) Intravenous secretin for autism spectrum disorder. Cochrane Database Syst Rev. 2005;(3):CD003495.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.