Status
Active
Medical and Behavioral Health Policy
Section: Behavioral Health
Policy Number: X-43
Effective Date: 01/28/2015
Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services
based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are
responsible for medical advice and treatment of patients. Members with specific health care needs should consult an
appropriate health care professional.
AUTISM SPECTRUM DISORDERS: ASSESSMENT
Description:
Autism Spectrum Disorders (ASD) include Autistic disorder, Rett’s
disorder, childhood disintegrative disorders, Asperger’s syndrome,
and pervasive developmental disorders not otherwise specified
(NOS).
ASDs are cognitive and neurobehavioral disorders that are
characterized by impairments in three core areas: social interactions,
verbal and/or nonverbal communication, and restricted, repetitive
patterns of behavior. ASDs are complex and multifaceted conditions
for which there is no known specific etiology. The impairments of
these conditions are variable.
There are three aspects in the diagnostic assessment of ASD:
categorical diagnosis, dimensional assessment, and individual
patient evaluation.
 Categorical Diagnosis
To assist with diagnosis, the clinician makes use of informant
based measures, structured diagnostic interviews, observational
measures and symptom checklists
 Dimensional Assessment
Dimensional assessments focus on specific areas of functioning
such as intellectual, communication, adaptive, social, and
behavioral. These evaluations may include performance-based
measures, semi-structured interviews or informant-based
measures.
 Individual Patient Evaluation
A complete diagnostic evaluation includes an assessment of
how the member’s behaviors impact his/her social interactions,
development, communication, and adjustment.
This policy addresses initial assessment of ASD and assessment of
progress for members receiving intensive behavioral intervention for
ASD. Intensive behavioral intervention is an intensive,
multidisciplinary approach used to treat the symptoms of ASD and
may encompass treatment descriptors including, but not limited to,
Intensive Early Interventional Behavioral Therapy (IEIBT), Intensive
Behavior Intervention (IBI), Applied Behavioral Analysis (ABA), and
the Lovaas Method. This type of therapy focuses on identifying
behaviors that interfere with normal developmental processes,
understanding the relationship between a behavior and the
member’s environment, and modifying those behaviors to improve
the member’s functional capacity.
NOTE: A separate policy exists for Psychological and
Neuropsychological Testing, (X-45). Please refer to this policy
for any Assessment of Autism Spectrum Disorders that
includes psychological and/or neuropsychological testing.
Policy:
1The
I.
Initial Assessment
A. To ensure appropriate multidisciplinary care and use of
benefits, there will be a comprehensive, multidisciplinary,
diagnostic assessment completed within the past 12 months
on file for each member before health services for Autism
Spectrum Disorders are initiated. The diagnostic assessment
must indicate that the individual has the intellectual and
functional capacity to benefit from the type and intensity of
the services proposed and include ALL of the following:
1. Diagnostic assessment by a licensed Mental Health
Professional1; AND
2. Current diagnoses on all five (5) axes of the most recent
version of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) of the American Psychiatric
Association multiaxial system; AND
3. A complete medical evaluation by a licensed physician;
AND
4. Testing, supervised and interpreted by an independent,
licensed psychiatrist or Ph.D psychologist, including
standardized:
a. Intellectual testing; and
b. Adaptive testing; and
c. Communication testing; and
d. Autism measures (e.g., ADOS, CARS, ADI-R); AND
5. A comprehensive hearing test by an audiologist; AND
6. The member’s developmental history, focusing on
developmental milestones and delay; AND
7. Family history; examples of important information include
whether there are other family members with an ASD,
mental retardation, fragile X syndrome, or tuberous
sclerosis; AND
8. The member’s medical history such as signs of
deterioration, seizure activity, brain injury, head
circumference; AND
Mental Health Professional must meet the Minnesota Department of Human Services qualifications, as
set forth in Minn.Stat.245.4871, subd. 27 and Minn.Stat.245.462, subd. 18.
9. Lead screening for those members with mental
retardation; AND
10. Review of educational (school) system records; AND
11. Other evaluations and testing as indicated or as
necessary to confirm the diagnosis.
II.
Coverage:
Assessment of Treatment Progress
A. For a member participating in intensive behavioral
intervention for the treatment of an Autism Spectrum
Disorder, a summary document outlining the member’s
progress, based on the measures of progress
established in the member’s plan of care and
standardized testing results, must be submitted to the
Plan at least every 6 months. This summary document,
which may be used to determine the medical necessity
of ongoing treatment, must include ALL of the
following:
1. Current diagnoses on all five (5) axes of the most recent
version of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) of the American Psychiatric
Association multiaxial system; AND
2. Testing, supervised and interpreted by an independent
licensed Mental Health Professional2 who is qualified to
administer appropriate assessment instruments, must be
administered, at the time intervals described below.
Testing must include standardized:
a. Intellectual testing, every 12 months; and
b. Adaptive testing, every 6 months; and
c. Communication testing, every 6 months; and
d. Autism measures (e.g., ADOS, CARS, ADI-R), every
6 months.
Blue Cross and Blue Shield of Minnesota medical policies apply
generally to all Blue Cross and Blue Plus plans and products. Benefit
plans vary in coverage and some plans may not provide coverage
for certain services addressed in the medical policies.
Medicaid products and some self-insured plans may have additional
policies and prior authorization requirements. Receipt of benefits is
subject to all terms and conditions of the member’s summary plan
description (SPD). As applicable, review the provisions relating to a
specific coverage determination, including exclusions and limitations.
Blue Cross reserves the right to revise, update and/or add to its
medical policies at any time without notice.
For Medicare NCD and/or Medicare LCD, please consult CMS or
National Government Services websites.
2
The Mental Health Professional must meet the Minnesota Department of Human Services qualifications, as
set forth in Minn.Stat.245.4871, subd. 27 and Minn.Stat.245.462, subd. 18.
Refer to the Pre-Certification/Pre-Authorization section of the
Medical Behavioral Health Policy Manual for the full list of services,
procedures, prescription drugs, and medical devices that require
Pre-certification/Pre-Authorization. Note that services with specific
coverage criteria may be reviewed retrospectively to determine if
criteria are being met. Retrospective denial of claims may result if
criteria are not met.
Coding:
The following codes are included below for informational purposes
only, and are subject to change without notice. Inclusion or exclusion
of a code does not constitute or imply member coverage or provider
reimbursement.
CPT:
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services
92553 Pure tone audiometry (threshold); air and bone
92556 Speech audiometry threshold; with speech recognition
92557 Comprehensive audiometry threshold evaluation and speech
recognition (92553 and 92556 combined)
92620 Evaluation of central auditory function, with report; initial 60
minutes
92621 Evaluation of central auditory function, with report; each
additional 15 minutes
96101 Psychological testing (includes psychodiagnostic assessment
of emotionality, intellectual abilities, personality and
psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the
psychologist's or physician's time, both face-to-face time
administering tests to the patient and time interpreting these test
results and preparing the report
96102 Psychological testing (includes psychodiagnostic assessment
of emotionality, intellectual abilities, personality and
psychopathology, e.g., MMPI and WAIS), with qualified health care
professional interpretation and report, administered by technician,
per hour of technician time, face-to-face
96103 Psychological testing (includes psychodiagnostic assessment
of emotionality, intellectual abilities, personality and
psychopathology, e.g., MMPI), administered by a computer, with
qualified health care professional interpretation and report
96118 Neuropsychological testing (e.g., Halstead-Reitan
Neuropsychological Battery, Wechsler Memory Scales and
Wisconsin Card Sorting Test), per hour of the psychologist's or
physician's time, both face-to-face time administering tests to the
patient and time interpreting these test results and preparing the
report
96119 Neuropsychological testing (e.g., Halstead-Reitan
Neuropsychological Battery, Wechsler Memory Scales and
Wisconsin Card Sorting Test), with qualified health care professional
interpretation and report, administered by technician, per hour of
technician time, face-to-face
96120 Neuropsychological testing (e.g., Wisconsin Card Sorting
Test), administered by a computer, with qualified health care
professional interpretation and report
96125 Standardized cognitive performance testing (e.g., Ross
Information Processing Assessment) per hour of a qualified health
care professional's time, both face-to-face time administering tests to
the patient and time interpreting these test results and preparing the
report
H2000 Comprehensive multidisciplinary evaluation
S9152 Speech Therapy, re-evaluation
V5008 Hearing screening
V5362 Speech Screening
V5363 Language Screening
Deleted Codes: 90801, 90802, 90862, 92506
Policy
History:
Developed March 11, 2009
Most recent history:
Reviewed January 11, 2012
Revised January 9, 2013
Reviewed/Updated, no policy statement changes January 8, 2014
Reviewed January 14, 2015
Cross
Reference:
Metallothionein (MT) Protein Assessment and Treatment Protocols,
X-03
Communication Assist Devices, VII-52
Psychological and Neuropsychological Testing, X-45
Current Procedural Terminology (CPT®) is copyright 2014 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative values, or
related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
Copyright 2015 Blue Cross Blue Shield of Minnesota.