Description

Autism Spectrum Disorder (ASD) Treatment Services include a variety of behavioral interventions. Healthy Blue recognizes those behavioral interventions that are identified as evidence-based by nationally recognized research reviews, and those identified and supported with substantial scientific and clinical evidence.  

Services to treat ASD, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) are provided to eligible Medicaid beneficiaries ages 0 to 21. ASD services must be recommended by a Licensed Psychologist, Developmental Pediatrician, or a Licensed Psycho- Educational Specialist (LPES) within his or her scope of practice under the South Carolina State law to prevent the progression of ASD, prolong life, and promote the physical and mental health and efficacy of the individual. These services may be provided in beneficiary’s home, clinical setting, or other settings as authorized.  

Non-Applied Behavioral Analysis ASD Treatment Services by a Licensed Indeoendent Practitioner (LIP):
Non-ABA ASD Treatment services can only be rendered by a LIP after receiving prior authorization once an IPOC has been submitted and approved. ASD treatment services are EBP that support the amelioration and management of symptoms specific to the diagnosis of ASD. Direct beneficiary contacts (and collaterals as clinically indicated). 

Allowable Non-ABA EBPs for ASD treatment services by a LIP include: 
•    Cognitive Behavioral Intervention Package (CBIP).
•    Comprehensive Behavioral Treatment for Young Children (CBTYC).
•    Language Training (Production).
•    Modeling.
•    Naturalistic Teaching Strategies (NTS).
•    Parent Training Package.
•    Peer Training Package.
•    Pivotal Response Treatment.^®
•    Schedules.
•    Scripting.
•    Self-Management.
•    Social Skills Package. 
•    Story-based interventions. 

Definitions:
Autism Spectrum Disorder refers to a disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. This disorder is best characterized as neurobiological disorder of uncertain etiology, with symptom onset in the first years of life. Heritability is polygenic and estimated to be 90 percent. The primary phenomenon in ASD is severe impairment in development of social skills. Other deficits that may be observed include failure to initiate play or social interaction, inability to generalize learned behavior to new situations, failure to share attention with others, poor sleep, temper tantrums, and hyperactivity.

Individualized Plan of Care (IPOC)is a comprehensive plan of care that outlines the service delivery to address the specific strengths and needs of the beneficiary. Here are the key elements of an IPOC:

Provider Qualification Table

Practitioners allowed to enroll directly with the Medicaid program include Licensed Psychologists, LPES, LISW-CP, LMFT, LPC, BCBA-D, BCBA, and BCABA.

Policy:

Medically Necessary:

All Medicaid beneficiaries must be ages 0 to 21 and have an established ASD diagnosis to meet medical necessity criteria in order to receive ASD treatment services.

Documenting Medical Necessity

A Licensed Psychologist Developmental Pediatrician or a LPES certified by the South Carolina Department of Education to perform such evaluations, and acting within the scope of their competency, must certify and document through a comprehensive psychological assessment/ testing report that the beneficiary meets the medical necessity criteria for services via a DSM ASD diagnosis.

Comprehensive Psychological Assessment/Testing Report

For new beneficiaries receiving ASD services, comprehensive psychological assessment/testing report must include:

1. A clinical interview with the beneficiary and/or family members or guardians as appropriate.
2. A review of the presenting problems, symptoms and functional deficits, strengths and history, including past psychological assessment reports and records.
3. Assessments also include a behavioral observation in one or more settings.
4. Autism Diagnostic Observation Schedule (ADOS).
5. A standardized measure of intelligence (e.g. WISC or WAIS, Stanford-Binet, Bayley Scales, etc.).
6. An ASD diagnosis from the current edition of the DSM, including severity levels.

Assessments may also include one or more of the following*:

• Autism Diagnostic Interview (ADI)
• Behaviorr Assessment System for Children (BASC)
• Childhood Autism Rating Scale (CARS)
• Gilliam Autism Rating Scale (GARS)
• Vineland Adaptive Behavioral Scales (Vineland)
• Assessment of Basic Language and learning Skills (ABLLS-R)
• Social Responsiveness Scale (SRS)
• Screening checklists (e.g., MCHAT, STAT, ASQ, etc.)

*Please note that while the list is not exhaustive, the measures utilized must be standardized.

Service Documentation

The comprehensive psychological assessment/testing report must include the following information:

• The beneficiary’s name and date of birth
• The date of evaluation session(s) and date of the report
• Referral question and/or reason for assessment
• Administered tests
• Medical history and medications
• Family history
• Psychological and/or psychiatric treatment history including previous psychological assessment/testing reports, etc.
• Substance use history
• Beneficiary and/or family strengths and support system
• Exposure to physical abuse, sexual abuse, anti-social behavior or other traumatic events
• A diagnosis from the current edition of the DSM, including levels or severity
• Recommendations for additional services, support, or treatment based on medical necessity criteria, including specific rehabilitative services (e.g., occupational therapy, speech therapy, etc.)
• The name of the Psychologist, LPES or Developmental Pediatrician; professional title, signature, and date

Beneficiaries with a Prior Established Diagnosis

A prior-established diagnosis is acceptable provided the comprehensive psychological assessment/testing report adheres to the medical necessity guidelines. The following guidelines must be used to determine medical necessity:

In addition to a behavioral observation and caregiver clinical interview, acceptable instruments to establish an ASD diagnosis must include at least three of the following, one of which must be an ASD-specific diagnostic tool:

• ADOS
• ADI
• CARS
• GARS
• Vineland
• ABLLS-R
• SRS
• BASC
• SCQ
• A standardized measure of intelligence (e.g., WISC or WAIS, Stanford-Binet, Bayley Scales, etc.)
• Screening checklists (e.g. MCHAT, STAT, ASQ, etc.)

The comprehensive psychological assessment/testing report must also include the following information:

• The beneficiary’s name and date or birth
• The date of evaluation session(s) and date of the report
• Referral questions and/or reason for assessment
• Administered tests
• A psychiatric diagnosis from the current edition of the DSM or the International Statistical classification of Diseases and related Health Problems (ICD)
• The name of the Psychologist or LPES, professional title, signature and date

From these documents medical necessity is met if the services are shown to prevent the progression of ASD, prolong the life of the member and/or promote the physical and mental health and efficacy of the individual.

Reporting/Documentation:

The clinical record must contain documentation sufficient to justify Medicaid reimbursement and should allow an individual not familiar with the beneficiary to evaluate the course of treatment.

The beneficiary’s clinical record must include, at a minimum, the following documentation:

• A Comprehensive Assessment/Testing Report which establishes medical necessity via an ASD diagnosis
• A Behavioral Identification Assessment for ABA services
• Signed, titled and dated IPOC
• Signed releases, consents, Beneficiary Rights acknowledgment, and confidentiality assurances for treatment
• Signed, titled and dated clinical service note (CSN) and progress summaries
• Copies of all written reports, and any other documents relevant to the care and treatment of the beneficiary
• Consent for treatment that is dates and signed by the beneficiary, parent, legal guardian or primary care giver or legal representative. A new consent should be signed and dated with each authorization
• Transition/discharge planning
• Coordination of care
• Emergency safety interventions

**All ASD treatment services must be documented in CSNs within five (5) business days of their delivery. ABA providers must document in accordance with ABA standards and guidelines. All other providers’ CSNs must include the nature of the beneficiary’s treatment, any changes in treatment, discharge, crisis interventions and any changes in medical, behavioral or psychiatric status. Documentation must justify the amount of reimbursement claimed to Medicaid.

At minimum, all CSN’s requires documentation of the following elements:

• Date
• Face to face time start and end time
• Individuals present during the visit
• Brief description of services provided
• Clinical note on the recipient’s behavior
• Place of service/delivery setting
• Any communication with guardians/ caregivers
• Signature of rendering provider with title
• All elements must be documented in legible handwriting
• Corrections to the medical record must adhere to the following guidelines:
  • For paper record corrections draw one line through the error, and write “error”, “ER”, “mistaken entry” or “ME” to the side of the error in parenthesis. Enter the correction, sign or initial, and date it.
  • Errors cannot be totally marked through; the information in error must remain legible. No correction fluid may be used.
  • For electronic health records, error correction must include date/time stamp and user ID.
• Late Entries should rarely be used, and then only used to correct a genuine error of omission or to add new information that was not discovered until a later date. Whenever late entries are made adhere to the following:
  • Identify the new entry as a “late entry”
  • Include date/time and identify or refer to the date and incident for which late entry is written

The IPOC must be individualized and specify problems to be addressed, goals to be worked toward and the strengths of the beneficiary. The IPOC must be developed prior to the delivery of a service with the full participation of the beneficiary and his or her family. The IPOC must be completed in its entirety and include the following:

• Beneficiary’s strengths, needs, abilities and preferences
• Goals and objectives of treatment which tie into the assessment and evaluation results
• Outline to address the assessment needs
• Specific treatment activities and interventions
• Amount and type of parent/caregiver participation, as applicable
• Date of each completed progress summary and annual re-development
• Signature, title, and date by the multidisciplinary team members including parent or caregiver

**The IPOC must be completed no later than the 10th business day after an initial assessment meeting. If the IPOC is not completed within this timeframe, services rendered are not Medicaid reimbursable. The IPOC must be reviewed as part of the regular progress summary and the progress summaries must be completed at least quarterly. A new IPOC must be developed every 12 months.

Discussion:

The clinical approach to a parent’s initial complaints about developmental abnormalities is dictated by age. Parents may bring the child in to the physician as young as 12 months, though generally the first contact is around 24 months or later. With children under 24 months, it will be more problematic to arrive at correct and stable diagnosis, delaying an accurate diagnosis. This serves to underline the importance of the physician’s skills, knowledge and experience. Parents who already have a child with ASD are often sensitized to early symptoms and these children are often brought in at even earlier ages. The estimated risk for ASD in younger siblings in identified patients is five percent.

Practice parameters for screening: these require immediate further evaluation:

• No babbling by 12 months
• No gesturing by 12 months (pointing, waving bye-bye, etc.)
• No single words by 16 months
• No two-word spontaneous phrases by 24 months
• ANY loss of ANY language or social skills at ANY age (Filipek, Accardo, Baranck, 1999)

The evaluation of individuals who test positive on a specific test or meet the practice parameters should commence a diagnostic evaluation with a complete history and physical examination, performed by a clinician experienced in the evaluation of ASD, in an attempt to determine a working diagnosis. This should include a complete history of the pregnancy, labor and delivery, exposure to toxins, drugs, infections and delivery complications. A full developmental history of all milestones of infant development also needs to be obtained, which would include the assessment of regression for previously learned abilities.

Further testing may include, but not be limited to:

• Vision and audiometric screening.
• IQ evaluation.
• Speech and language evaluation.
• Blood work: CBC, thyroid.
• Other labs (as indicated): metabolic studies (amino and organic acids, ammonia, lactate, etc.), cytogenetic studies (high resolution chromosome studies, Fragile X testing, translocation/deletion syndromes, etc.)
• Imaging: MRI of brain (not typically indicated).
• EEG (sleep deprived may be preferred), especially with a history of seizure spectrum behavior.
• Consults with psychiatrist, neurologist, pediatrician, psychologist, speech, occupational and/or physical therapist, etc., as indicated.

Medical conditions associated with autistic-like behaviors include, but are not limited to:

• Seizure Disorder.
• Hearing problems.
• Fetal alcohol syndrome.
• Trisomy 21.
• Goldenhar syndrome.
• Hypothyroidism.
• Phenylketonuria.
• Cornelia de Lange syndrome.
• Neurofibromatosis.
• Tourrette’s syndrome.
• Dandy-Walker Syndrome.
• Myoclonic epilepsy of infancy (Dravet Syndrome).
• Doose syndrome: myoclonic astatic seizures.

There is also an emerging literature that suggests international adoption, and perhaps family movement to another language/culture, may severely impact infants, toddlers and preschoolers in the early phases of cognitive language development, such that autistic like behaviors may occur. This may be referred to as a disruption of cognitive language development, as opposed to communicative language development.

ABA for ASD includes efforts to extinguish negative behaviors, and to replace these with positive behaviors by improving skills, based upon Skinnerian concepts of conditioned responses. Another focus would be the development of the ability to generalize concepts already learned to novel situations. Aside from a concentration on the core symptoms, there is a focus on attention and initiation as well. All involve a structured environment, predictable routines, functional as opposed to standardized treatment, a transition plan and significant family involvement. At the initial evaluation, target symptoms are identified, with designated interventions. There is also a need to provide an assessment mechanism at specified intervals.

ABA services for young children are often referred to as Early Intensive Behavioral Intervention (EIBI). EIBI targets cognition, language, social skills, etc. These services have typically been provided to children ages 8 and under for a duration of two to three years. During an average week, these services may be provided for up to 40 hours. Although the literature is clear that 10 hours per week results in a less robust therapeutic response, it remains unclear as to the optimal number of hours/week. After these preschool years, services may be provided by the child’s school, as well as in the child’s home. For children above the age of 10 years, services requested may focus on the development of social skills. Much of the ABA research has focused on children in the age range 2 – 7.

Other Therapies for ASD

Other therapies for ASD include, but are not limited to: Auditory Integration Therapy, Facilitated Communication, Developmental Individual-difference Relationship-based (DIR/Floortime) model, Relationship Development Intervention, Holding Therapy, Movement Therapies, Music Therapy, Pet Therapy, psychoanalysis, Son Rise Program, Scotopic Sensitivity Training, Sensory Integration Therapy, Neurotherapy (EEG biofeedback), gluten and casein free diets, mega-vitamin therapy, chelation of heavy metals, anti-fungal drugs for presumed fungal infection and secretin administration. There is insufficient evidence to support efficacy for a few of these treatments and no evidence for the majority. These programs are not considered to be Behavioral Therapy.

Aversive Techniques

Behavioral change techniques should use reinforcement whenever possible with consideration given to the least restrictive techniques possible. When punishment is chosen for a problem behavior, the techniques employed must follow the ethical guidelines dictated by the Behavior Analyst Certification Board. The parent or guardian must provide written consent for use of any techniques that may be considered aversive.

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Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community,

U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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