BlueCross and BlueShield of Montana Medical Policy/Codes
Autism Spectrum Disorders
Chapter: Mental Health
Current Effective Date: December 27, 2013
Original Effective Date: January 01, 2010
Publish Date: December 27, 2013
Revised Dates: April 7, 2011, June 3, 2011, October 12, 2011; June 1, 2013; December 27, 2013
Description

Autism is a complex and life-long developmental disability.  A broad range of developmental disorders are collectively known as Autism Spectrum Disorders (ASD); these disorders include the following:

  • Autism—the prototypical disorder of the group;
  • Asperger’s Syndrome—refers to individuals with autistic characteristics but relatively intact language abilities;
  • Pervasive Developmental Disorder—Not Otherwise Specified (PDD-NOS)/ Atypical Autism—refers to a collection of features that resemble autism but may not be as severe or as extensive;
  • Rhett’s Disorder—relatively rare, primarily affects females, and is a genetic disorder with hard neurological signs (including seizures) that become more apparent with age;
  • Childhood Disintegrative Disorder (CDD)—rare, primarily affects males, and refers to children whose development appears normal for the first few years, but then regresses with loss of speech and other skills until the characteristics of autism are apparent.

The estimated prevalence of autism ranges from 2-6 per 1000 children; it is more prevalent in boys than girls.  While autism can be diagnosed at any age, it is usually diagnosed by age three years through late preschool age.  Milder conditions within the autism spectrum, including Asperger’s Syndrome and PPD-NOS may present later, if at all, and can be more difficult to recognize.  Rhett’s Syndrome and Childhood Disintegrative Disorder are rare, but are more severe disorders.  The following core features of ASD form the basis for diagnostic criteria used by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):

  • Impaired social interaction and social development,
  • Impaired language, verbal and non-verbal communication,
  • Restrictive and repetitive behavior patterns.

Possible indicators of ASD include:

  • Does not babble, point, or make meaningful gestures by one year of age;
  • Does not speak one word by 16 months of age;
  • Does not combine two words by two years of age;
  • Loses language or social skills.

Other indicators that may be present are:

  • Does not respond to name;
  • Poor eye contact;
  • Doesn’t seem to know how to play with toys;
  • Excessively lines up toys or other objects;
  • Is attached to one particular toy or object;
  • Doesn’t smile;
  • At times seems to be hearing impaired;
  • Unprovoked aggressive or violent behavior toward self or others;
  • Problems with attention, concentration, or sleep;
  • Unusual or inappropriate responses to sensory stimuli;
  • Self-injury;
  • Property destruction;
  • Pica (a perverted appetite for substances not fit as food or of no nutritional value, e.g., clay, dried paint, starch, ice);
  • Defiance and tantrums; 
  • Not wanting to cuddle or to be cuddled; or
  • Physical over-activity or under-activity.

Children and adults with autism can exhibit any combination of these behaviors in any degree of severity.  Also, two children with the same ASD diagnosis can behave completely different from each other and have different capabilities.

Early in life, developing infants are social beings; they gaze at people, turn toward voices, grasp a finger, smile.  In contrast, autistic children have difficulty learning to engage in everyday human interaction.  They avoid eye contact, prefer to be alone, seldom seek comfort or respond to parents’ displays of anger or affection.  They can be slower to learn to interpret social cues, such as a smile, a wink, or a grimace, and they appear to have difficulty seeing things from another person’s perspective.  They also have difficulty regulating their emotions, which leads to apparent “immature” behavior, inappropriate emotional outbursts, disruptive behavior, and physical aggression.  Some autistic children remain mute throughout their life. Those who do speak may use language in unusual or inappropriate ways; for example, they may not be able to combine words into meaningful sentences, or they may speak only one word or repeat the same word(s) over and over.  Children who have milder forms of ASD may exhibit slight delays in language, or they may have large vocabularies but have difficulty carrying on a conversation.  In addition, their body language may not be appropriate to what they are saying.  Repetitive behavior in autism can take the form of persistent, intense preoccupation.  Consistency in the environment is very important as a small change in routine can be extremely disturbing to the autistic child.

Although autism is considered a neurological disability, the etiology is unknown.  A number of causes have been suggested, including genetics and heredity, problems during pregnancy or delivery, viral infections, metabolic imbalances, exposure to environmental chemicals, harmful substances ingested during pregnancy, and vaccines; none of these have been proven.  Many children with ASD have some degree of mental retardation/intellectual disability, and about one in four develop seizures.  Children with ASD tend to have certain medical conditions more often than expected, such as FraX, tuberous sclerosis, congenital rubella syndrome, and untreated phenylketonuria (PKU).  FraX, in which the X chromosome is defective, is the most common inherited form of mental retardation/intellectual disability, and occurs in about 2-5% of people with ASD. If a child with ASD also has FraX, there is a 50% chance that boys born to the same parents will have the syndrome.  Tuberous Sclerosis is a rare genetic disorder that is present in 1-4% of people with ASD.

A variety of treatment approaches have been developed that address the social, language, and behavioral difficulties of ASD.  While many have not been proven to be effective, some general guidelines have emerged.  Generally, interventions should

  • begin early and focus on teaching functional skills of immediate and ongoing value in daily life,
  • be individualized to the type and severity of symptoms,
  • provide structure and clear guidelines, and
  • include family involvement.

Applied Behavioral Analysis (ABA), an Early Intensive Behavioral Intervention (EIBI), encompasses behavior modification training programs that are based on the theory that behavior is learned through interaction between an individual and the environment.  The goal of behavior management is to reinforce and increase desirable, functional behaviors while reducing undesirable, “maladaptive” behaviors.  Lovaas therapy is an ABA-based program developed by Ivar Lovaas, Ph.D., at the UCLA Clinic for the Behavioral Treatment of Children.  Lovaas therapy uses an ABA method called Discrete Trial Training, which consists of a series of distinct repeated lessons or trials taught one-to-one. Typically the lessons are highly intensive, usually taking 30-40 hours per week, and are conducted by a trained therapist, usually in the family’s home.  Each trial consists of a request for the individual to perform an action, behavior, or response, and involves a consequence or reaction from the therapist.  Positive reinforcement rewards vary and are matched to the individual child.

Other types of intensive interventions that use ABA techniques include LEAP (Learning Experiences and Alternative Programs), TEACCH (Treatment and Education of Autistic and Related Communication of Handicapped Children), the Denver program, and the Rutgers program.  LEAP, is a comprehensive program for young children that includes peer-mediated instruction, incidental teaching, self-management training, prompting strategies, and systematic parent training.  TEACCH uses a structured teaching approach based on the idea that the environment should be adapted to the child, not the autistic child to the environment.  The child’s learning abilities are assessed using a Psycho Educational Profile (PEP) and, based on the child’s functioning level, teaching strategies are designed to improve communication, social, and coping skills to help the child understand his environment and the behavior of other people.  The Denver program is a developmental-based program that focuses on the development of communication and play skills, sensory activities, personal independence, and reducing unwanted behaviors.  The Rutgers program is an early intensive behavioral intervention program that is home-based and is similar to Lovaas therapy, except that the program staff doesn’t deliver treatment directly; the staff provides training and follow-up to the family and school, with the goal to gradually integrate the child into the classroom.

Picture Exchange Communication Systems (PECS) was developed to help autistic children acquire functional communication skills.  PECS uses ABA-based methods to teach children to exchange a picture for something they want—an item or an activity. 

Pivotal Response Treatment (PRT) is a “naturalistic” intervention model that targets pivotal areas of a child’s development.  In PRT, the child’s intentional attempts at functional communication are rewarded with a natural reinforcer.  For example, if a child attempts a request for a stuffed animal, the child receives the animal, not a piece of candy or other unrelated reinforcer.  PRT is used to teach language, decrease disruptive behavior, and increase social, communication, and academic skills.

Floor time is an educational model that builds an increasingly larger circle of interaction between the child and adult in a developmentally-based sequence.  Floor time addresses emotional development, in contrast to other approaches that tend to focus on cognitive development.  Floor time is often used in conjunction with other methods, such as ABA.

Social stories were developed as a tool for teaching social skills.  The stories have three types of sentences: descriptive to explain what is happening, perspective to provide insight, and directive to suggest a response.  The stories can be written by anyone, are specific to the child’s needs, and are written in first person and present tense.  The story should address the child’s misunderstanding of situations that are frightening to him, produce tantrums or crying, or make the child withdraw, and should teach the child how to deal with those feelings.

Facilitated communication (FC) involves a facilitator who, by supporting the individual’s hand or arm, helps the person communicate through use of a computer or typewriter.  FC is very controversial; critics claim it is actually the ideas or thoughts of the facilitator that are being communicated.

Sensory integration therapy (SIT) focuses on desensitizing the child and helping him reorganize sensory information.  The goal is to help the nervous system develop the ability to process sensory input more normally.  Touch therapy is a particular method of massage. 

Auditory integration training (AIT) involves listening through earphones to music that has been electronically modulated based on the individual’s audiogram. AIT is thought to improve attention, auditory processing, and auditory comprehension. 

Relationship Development Intervention (RDI) training was developed by a husband-and-wife team of clinical psychologists, Steven Gutstein, PhD, and Rachelle Sheely, PhD.  The goal of RDI training is to teach the child how to develop social relationships with other people, starting with their parents.  A consultant teaches the parents how they can help the child develop a social relationship with the parents and others, through various activities, e.g., playing games, mimicking facial expressions, etc.

Other interventions include music, art and animal therapy (e.g., horseback riding, swimming with dolphins), administration of intravenous secretin or immune globulin, chelation therapy, special diets, and vitamin and mineral supplements.  Music, art and animal therapy are believed to improve communication skills, develop social interaction, reduce behavioral symptoms, and provide a sense of accomplishment.  Use of immune globulin is based on the assumption that autism is caused by an autoimmune abnormality.  Secretin, a peptide hormone that stimulates the pancreas and liver, is thought to be useful to manage autistic behavior based on theories of gastrointestinal disorders as the cause of autism.  Chelation therapy, which uses medications to help the body eliminate toxins, is based on mercury exposure as a possible cause of autism.  Restrictive or special diets are based on the idea that autism is caused by digestive disorders or food allergies.  Nutritional supplements are based on the theory that vitamin B6 and magnesium can improve autistic behavior.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Certain procedures and services (listed below) may be considered medically necessary when performed for the assessment, diagnosis, and/or treatment of Autism Spectrum Disorders (ASD) in any of the following circumstances:

  • No babbling by age 12 months;
  • No gesturing by age 12 months (e.g., pointing, waving bye-bye);
  • No single words by age 16 months;
  • No two-word spontaneous phrases (not just echolalic) by age 24 months; and/or
  • Any loss of any language or social skills at any age.

For patients who meet the above criteria, the services and procedures that may be considered medically necessary for diagnosis and treatment of autism include ANY of the following:

  • Developmental surveillance at all well-child visits, including but not limited to:
    1. Medical evaluation and screening,
    2. Parent and/or child interview, including siblings with autism;
  • Formal audiological evaluation;
  • Evaluation (not treatment) by a Speech-Language Pathologist (See THE803.014, Speech Therapy for coverage criteria)  (NOTE:  See Legislation section for mandated coverage);
  • Speech and language therapy for treatment of comorbid impairment.  (NO  See Legislation section for mandated coverage) (See THE803.014, Speech Therapy for coverage criteria)
  • Evaluation by Occupational Therapist and/or Physical Therapist for comorbid physical impairment (See THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services for coverage criteria) (NOTE:  See Legislation section for mandated coverage);
  • Physical and/or occupational therapy for treatment of comorbid impairment (See THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services for coverage criteria) (NOTE:  See Legislation section for mandated coverage);
  • Blood lead level screening if developmental delay, exposure to high-risk environment, or pica are present;
  • Genetic testing, specifically high resolution chromosome studies (karyotype) and/or DNA analysis for Fragile X Syndrome (FraX), in any of the following situations:
    1. Mental retardation/intellectual disability either is present or cannot be excluded,
    2. Family history of either FraX, mental handicap, or learning disability,
    3. Dysmorphic physical features are present;
  • Quantitative plasma amino acid assay to detect phenylketonuria;
  • Selective metabolic testing (e.g., amino acids, organic acids, carnitine, trace metals) and/or toxicology studies, if any of the following are present:
    1. Lethargy,
    2. Cyclic vomiting,
    3. Early seizures,
    4. Dysmorphic or coarse features,
    5. Mental retardation/intellectual disability (either is present or cannot be ruled out),
    6. Occurrence or adequacy of newborn screening for birth defect is questionable;
  • Epileptiform sleep-deprived electroencephalogram (EEG) if any of the following are present:
    1. Clinical seizures,
    2. Suspicion of subclinical seizures (e.g., staring spells),
    3. History of developmental regression, i.e., clinically significant loss of social or communicative function at any age, but especially in toddlers and preschoolers.

Procedures, service, and therapies that are considered experimental, investigational and unproven for the routine diagnosis and/or treatment of ASD include, but are not limited to:

  • Event-related brain potentials;
  • Magnetoencephalography;
  • Functional imaging modalities, including:
    1. Functional magnetic resonance imaging (fMRI),
    2. Single-photon emission computed tomography (SPECT),
    3. Positron-emission tomography (PET);
  • Allergy testing (particularly food allergies for gluten, casein, candida, and other molds);
  • Hair analysis for trace elements;
  • Tests for:
    1. Celiac antibodies,
    2. Immunologic or neurochemical abnormalities,
    3. Micronutrients such as vitamin levels,
    4. Intestinal permeability studies,
    5. Stool analysis,
    6. Urinary peptides,
    7. Mitochondrial disorders, including lactate and pyruvate,
    8. Thyroid function,
    9. Erythrocyte glutathione peroxidase studies.
  • Elimination diets;
  • Nutritional supplements;
  • Intravenous immune globulin infusion;
  • Secretin infusion;
  • Chelation therapy and/or Hyperbaric Oxygen Therapy (HBOT) (either alone or in combination).
  • Sensory Integration Therapy (SIT);
  • Auditory Integration Therapy (AIT);
  • Music therapy;
  • Vision therapy;
  • Touch or massage therapy;
  • Social stories;
  • Floor time;
  • Facilitated communication;
  • Picture Exchange Communication Systems;
  • Pivotal Response Treatment;
  • Hippotherapy, animal therapy, or art therapy;
  • Relationship Development Intervention (RDI);
  • Applied Behavior Analysis (ABA) and other Early Intensive Behavioral Intervention (EIBI) programs(**see NOTE below for mandated coverage) (examples of EIBI include, but are not limited, to Lovaas therapy, discrete trial training, LEAP (Learning Experiences and Alternative Programs), TEACCH (Treatment and Education of Autistic and Related Communication of Handicapped Children), the Denver program, the Rutgers program, etc.)

**NOTE:  When coverage of ABA and/or EIBI are state-mandated or specifically included in a member’s benefit plan, the following medical necessity criteria will be applied for A) initial therapy, or B) continued therapy, or C) discontinuation of therapy:

A.  Criteria for Initial therapy (all criteria must be met):

  1. The medical records confirm that a DSM-IV diagnosis of a Pervasive Developmental Disorder has been established by formal developmental and/or psychometric evaluation; AND
  2. A  behavior is present that:
    • Presents a health or safety risk to self or others (such as self-injury, aggression toward others, destruction of property, stereotyped and/or repetitive behaviors, elopement, severe disruptive behavior); or
    • Interferes with home or community or age appropriate activities; AND
  3. A formal treatment plan has been developed, including:
    • The proposed treatment(s) by type; and
    • The frequency of the proposed treatment(s); and
    • The anticipated duration of the treatment(s); and
    • The anticipated outcomes stated as individualized goals; and
    • Objectives that are measurable and tailored to the patient; and
    • Parent or caregiver training and support is incorporated into the treatment plan; and
    • The interventions emphasize generalization of skills and focus on the development of spontaneous social communications, adaptive skills and appropriate behaviors; and
    • The interventions are consistent with ABA techniques; AND
  4. There is a reasonable expectation by the evaluating health care professional that the patient can actively participate, and that the individuals’ behavior will improve OR progress can be seen with the therapy; AND
  5. Physician’s order is submitted for the therapy.

B.  Criteria to Continue Therapy (all criteria must be met):

  1. The patient continues to meet the criteria defined in above initial criteria OR there is the appearance of new problems or symptoms that meet initial criteria; AND
  2. There is a reasonable expectation by the ordering health care professional that the patient will benefit from the continuation of therapy services; AND
  3. The treatment plan is updated every six (6) months; AND
  4. The contemporaneous medical record documents measurable progress compared to the treatment objectives; AND
  5. Treatment is not making the symptoms persistently worse.

C.  Criteria to Discontinue Therapy (when any of the following are present):

  1. There is no measurable progress documented in the medical record regarding the patient’s behavior(s) for period of six (6) months of interventions as identified in above treatment plan requirements.  (NOTE:  Measurable progress must be durable over time beyond the ends of the actual treatment session, and generalizable outside of the treatment setting to the patient’s residence and to the larger community within which the patient resides); OR
  2. The treatment is making the symptoms persistently worse; OR
  3. The patient demonstrates an inability to maintain long-term gains from the proposed plan of treatment.

Rationale

ASD diagnoses are complex; developmental disorders and associated co-morbidity commonly overlap.  No specific medical test or procedure can confirm an autism diagnosis, and there is no proven cure.  Although anecdotal reports suggest certain interventions may benefit some children, the same interventions may be entirely unhelpful for others.  Little comparative research between treatment approaches has been done, partly because there are so many variables to be controlled.  Various developmental, behavioral, and educational strategies have been developed and many have been adopted by various groups.  Most have not been subjected to thorough, sound research that proves evidence of effectiveness, and there is no consensus regarding which strategy is most effective. 

The American Academy of Neurology (AAN) has reviewed empirical evidence and developed practice parameters giving recommendations for the screening, diagnosis, and management of autism.  The AAN practice parameter has been endorsed by the American Academy of Audiology, the American Academy of Pediatrics (AAP), the American Occupational Therapy Association, the American Psychological Association, the American Speech-Language-Hearing Association, the Autism National Committee, Cure Autism Now, the National Alliance for Autism Research, and the Society for Developmental Pediatrics.  The AAN statement describes three levels of recommendations: 1) routine development surveillance and screening specifically for autism, 2) diagnosis and evaluation of autism, and 3) consensus-based principles of management. 

AAN recommendations for routine surveillance and screening include:

  • Developmental surveillance and screening at all well-child visits;
  • Further developmental evaluation whenever a child fails to meet any of the following:
    • Babbling and gesturing by 12 months,
    • Single words by 16 months,
    • Two-word phrases by 24 months, or
    • Loss of any language or social skills at any age;
  • Specific screening for autism using one of the validated instruments, e.g., the Checklist for Autism in Toddlers (CHAT) or the Autism Screening Questionnaire (ASQ);
  • Formal audiologic assessment using an experienced pediatric audiologist;
  • Lead screening in any child with developmental delay and/or pica, and repeat periodically if pica persists.

AAN recommendations for diagnosis and evaluation for autism include:

  • Genetic testing, specifically high resolution chromosome studies (karyotype) and DNA analysis for FraX syndrome if:
    1. Mental retardation/intellectual disability is present or cannot be excluded,
    2. There is family history of FraX or undiagnosed mental retardation/intellectual disability, or
    3. Dysmorphic features are present;
  • Selective metabolic testing if any of the following are present:
    1. Lethargy, cyclic vomiting, or early seizures,
    2. Dysmorphic or coarse features,
    3. Mental retardation/intellectual disability either is present or cannot be ruled out, and/or
    4. Occurrence or adequacy of newborn screening for birth defect is questionable;
  • Evidence is inadequate to recommend an EEG study in all individuals with autism; indications for an adequate sleep-deprived EEG with appropriate sampling of slow wave sleep include clinical seizures, suspicion of subclinical seizures, and/or a history of regression at any age; Recording of event-related potentials and magnetoencephalography are considered research tools at the present time;
  • Clinical evidence does not support the routine use of clinical neuroimaging in the diagnostic evaluation of autism, even in the presence of megalocephaly;
  • There is inadequate supporting evidence for hair analysis, celiac antibodies, allergy testing (particularly food allergies for gluten, casein, candida, and other molds), immunologic or neurochemical abnormalities, micronutrients such as vitamin levels, intestinal permeability studies, stool analysis, urinary peptides, mitochondrial disorders, thyroid function tests, or erythrocyte glutathione peroxidase studies.

AAN recommendations for management of ASD include:

  • Speech, language, and communication evaluation;
  • Occupational therapy and physical therapy evaluations;
  • Neuropsychological, behavioral, and academic assessments.

Functional neuroimaging studies, such as PET, SPECT, and fMRI, have revealed certain abnormalities, but the value of functional neuroimaging has not been established for diagnosis of autism.  During the 1970s computed tomography (CT) studies, which at that time were standard for assessing children with autism, reported a wide range of brain imaging abnormalities, suggesting associated underlying structural disorder.  However, Damasio et al. demonstrated that such abnormalities were incidental to coexisting anatomic disorders unrelated to autism.  Consequently, neuroimaging studies confirmed the absence of significant brain abnormalities.  The AAN review concluded that there is no evidence to support the role of routine clinical neuroimaging studies (PET, SPECT, or fMRI) in the clinical diagnosis of autism, even in the presence of megalencephaly. 

The incidence of epilepsy in autistic children is estimated at about 7% to 14%; the cumulative prevalence by adulthood is estimated at 20% to 35%.  However, the AAN review found inadequate evidence to recommend an EEG study in all individuals with autism.  Evidence did show that autism with regression and CDD have both been associated with seizures or epileptiform sleep-deprived EEG, with adequate sampling of slow wave sleep; these were more prevalent in children with regression who demonstrated cognitive deficits.  Also, there may be a causal relationship between a subgroup of children with autistic regression and EEG-defined “benign focal epilepsies.”  An adequate sleep-deprived EEG with appropriate sampling of slow wave sleep is indicated in the presence of clinical seizures or suspicion of subclinical seizures, or a history of regression of social or communicative function at any age.  The AAN also stated that there is insufficient evidence to suggest a role for event-related potentials or magnetoencephalography in the evaluation of autism.

There is a growing body of evidence that intensive early intervention therapy before five years of age may lead to better overall outcomes.  The “landmark” study of early intensive interventions with young children was done by Ivar Lovaas in the Young Autism Project at UCLA in 1987, with follow-up by McEachin and Lovaas in 1993.  Lovaas reported outcomes of treating children under age four years with 40 hours per week of one-to-one behavioral training using Applied Behavioral Analysis (Discrete Trial Training) for two years.  The training method focused on the acquisition of compliance behavior, imitation activities, language, and integration with peers using repeated discrete behavioral trials to accomplish the goals. After two years, almost 50% of the children in the treatment group were functioning typically in intellectual and academic areas. At five-year follow-up, most had maintained their gains.  The major criticisms of the study are nonuniform participant selection, lack of clear standard diagnostic criteria at entry, the required intensity level of the intervention for such young children, choice of outcome measures, and randomization issues.  Also, Lovass noted that strict random assignment to each group was not done due to parent protest and ethical considerations. 

In 1998, Sally J. Rogers of the Department of Psychiatry at the University of Colorado’s School of Medicine described seven studies that attempted to replicate Lovass’ findings.  She noted that although positive outcomes were reported in every trial, the evidence did not demonstrate that this approach met present criteria for well-established or efficacious treatment.  The major flaws she noted were no follow-up and/or either no control group or no matched controls.  She concluded that certain variables, e.g., age, IQ, language level, etc., may affect outcomes and be significantly related to treatment response.

In 2000, the British Columbia Office of Health Technology Assessment (BCOHTA) conducted a systematic review of published studies to determine whether early, intensive behavioral therapy for children with autism results in normal functioning, or essentially a cure.  The BCOHTA criticized the studies, concluding that the Lovaas and McEachin studies are inadequate to establish the degree to which this therapy results in children achieving ‘normal’ function, however defined, and there is insufficient evidence to establish a relationship between the amount of therapy (per day and total duration) and overall outcome. 

In 2001, the National Research Council, including the National Academy of Sciences, formed a committee to integrate the scientific, theoretical, and policy literature for evaluating the scientific evidence concerning the effects of educational interventions for young children with autism.  The committee reported there is little evidence concerning the effectiveness of discipline-specific therapies, and no adequate comparisons of different comprehensive treatments; research would provide more valuable information if there were minimal standards in design and description of intervention projects. 

In 2004, Doughty et al. published the New Zealand Health Technology Assessment, which is a technology brief that focused on the most recent and best evidence for the effectiveness of intensive behavior intervention and skill-based early intervention to manage autism.  This report concluded that it remains to be determined if any one early and/or intensive intervention program is more effective than another.  In addition, it was not clear that the definition of intensive behavioral treatment, parent training, or parent-managed behavioral therapy were uniform across individual studies.  Intensity and duration of interventions were not documented in all studies, and sample sizes were small. 

Other comprehensive educational programs have been developed specifically for children with ASD, including TEACCH, Daily Life Therapy (the Higashi School), and Bright Start, among others.  The most well known program, TEACCH has been evaluated by empirical studies of program components and parent evaluations, and has been found to be successful in its goal. However, these studies have not included control groups. 

Since 2003, The National Institute of Health (NIH) has been recruiting 50 subjects for one of the first randomized, double-blind, active control, parallel assignment efficacy studies using several behavioral approaches, including ABA.  Expected completion date is October 2007.

Occupational therapy using sensory integration techniques is sometimes used for children with ASD.  Although some believe occupational therapy is subjectively effective in educational and clinical settings, research data to support its effectiveness is scant.  Occupational and physical therapy may be helpful in addressing coordination and motor planning deficits occurring in some children with ASD.

Auditory integration training (AIT) is based on the unproven theory that symptoms in ASD are caused by auditory perception defects resulting in distortions of sound or auditory hypersensitivity (hyperacusis).  A single pilot study of 17 patients supported the hypothesis that AIT improved some autistic behaviors, but AIT did little to decrease hyperacusis.  In 2000, Mudford et al. conducted a crossover study that showed no difference between the AIT group and the control group.  Also in 2000, Dawson et al. reviewed evidence and concluded the studies do not support the use of either AIT or sensory integration therapy (SIT) for autism.

Facilitated communication (FC) is a somewhat controversial technique.  Bebko et al. found significant facilitator influence of responses, and that some students became even more passive communicators when FC is used.  Multiple scientific studies have failed to demonstrate the effectiveness of FC as a treatment, and it remains investigational.

Disorders of metabolism, nutritional supplements, and food allergies have each been studied as a cause of autism.  But the percentage of autistic children who have a metabolism disorder is probably less than 5%; some experts agree it is considerably less than 5%.  Findling et al. conducted a ten-week double-blind, placebo-controlled trial to determine both the efficacy and safety of high doses of pyridoxine and magnesium (HDPM) as a way to decrease physical aggression and improve social interaction in autism; HDPM was ineffective in this study.  Other investigations have failed to prove a higher prevalence of food allergies in children with ASD.  The AAN guidelines state that, for diagnosis and management of autism, there is inadequate supporting evidence for hair analysis, celiac antibodies, allergy testing (particularly food allergies for gluten, casein, candida, and other molds), immunologic or neurochemical abnormalities, micronutrients such as vitamin levels, intestinal permeability studies, stool analysis, urinary peptides, mitochondrial disorders (including lactate and pyruvate), thyroid function tests, or erythrocyte glutathione peroxidase studies.

Secretin, a peptide hormone that stimulates pancreatic secretion, has been presented as an effective treatment for autism, based on anecdotal evidence.  Multiple randomized, double-blind, placebo-controlled trials of both single and multiple doses of secretin have been published.  In 2005, a Cochrane Database Review concluded that there is no evidence that intravenous secretin, in either single or multiple doses, is effective in improving the core features of autism or the quality of life for affected individuals.

Concerns have been raised that ASD might be caused by early childhood exposure to environmental toxins, such as mercury from fish (methylmercury) or vaccines (thimerosal).  There are no published studies linking mercury exposure to the development of ASD or demonstrating that children with ASD have had greater exposure to mercury than have unaffected children.  Hair analysis and chelation tests may detect mercury level, but are not recommended; hair analysis is subject to false positive results, and there is no evidence that chelation therapy will improve developmental function when given for mercury toxicosis.  Also, chelating agents themselves can cause hepatotoxicity and allergic reaction.  However, children with developmental delay may exhibit pica, or may have more extensive hand-to-mouth activity than other children, and thus may be at increased risk for lead toxicity; the National Center for Environmental Health of the Centers for Disease Control and Prevention recommends lead poisoning screening for children with developmental delay, even without frank pica.

In some studies, cerebral hypoperfusion has been correlated with repetitive, self-stimulatory, and stereotypical behaviors, and impairments in communication, sensory perception, and social interaction.  Hyperbaric oxygen therapy (HBOT) has been used with some clinical success in several cerebral hypoperfusion conditions.  Several studies on the use of HBOT, and HBOT in combination with chelation, in autistic children are currently underway.  In 2007, Rossignol et al. conducted a prospective study of 18 children with autism, ages 3-16 years, who were given 40 HBOT sessions of 45 minutes each, either at 1.5 atmospheres (atm) and 100% oxygen, or at 1.3 atm and 24% oxygen.  Although some of the results did appear to be positive, the authors concluded that, since this was an open-label study, definitive statements regarding the efficacy of HBOT for the treatment of autism must await results from double-blind, controlled trials.

Immunologic abnormalities have been suggested as an autoimmune cause of autistic symptoms.  In 1999, A.V. Plioplys investigated whether intravenous immunoglobulin would improve autistic symptoms.  The study enrolled ten autistic children with immunologic abnormalities, as demonstrated on blood tests.  Only one child had significant improvement.  Once the treatment program was completed, this child gradually deteriorated over a five-month time period and fully reverted to his previous autistic state.  Plioplys concluded that the use of immunoglobulin to treat autistic children should be undertaken only with great caution, and only under formal research protocols. Larger controlled studies are needed to assess this kind of treatment, but there is no scientific evidence to justify the use of infusions of immunoglobulin to treat children with ASD.

There are insufficient well-constructed, scientific studies in the published literature that provide evidence to support the efficacy of vision therapy, touch therapy, massage therapy, PECS, PRT, floor time, social stories, hippotherapy, animal therapy, or art therapy for treatment of ASD. 

2011 Update

EIBI Based on ABA

In December 2010, Blue Cross Blue Shield Association (BCBSA) Technology Assessment Center (TEC) updated their 2009 “Special Report: Early Intensive Behavioral Intervention Based on Applied Behavior Analysis among Children with Autism Disorders.”  For this update, TEC conducted a systematic review of the research literature on the use of EIBI among young children with autism, pervasive developmental disorder or Asperger’s syndrome, and addressed three questions:

  • Question 1.  How effective is EIBI in improving the functioning of children with autism spectrum disorders, and how does it compare to other early intervention approaches?
  • Question 2.  Can patient characteristics be identified that predict better outcomes from EIBI?
  • Question 3.  Does the effect of EIBI vary with the intensity of treatment?

In the update, a literature search was conducted of articles in peer-reviewed journals published between 1966 (MEDLINE®) or 1970 (PsychLit®) and October 2010.  Nineteen studies (22 articles) were abstracted, including two randomized, controlled trials; 12 nonrandomized, comparative studies; and five single-arm studies.  No studies were found that included children with Asperger’s syndrome; four studies explicitly included children with PDD or PDD-NOS.  The four meta-analyses vary in their methodology, tools to assess study quality, studies included, and conclusions.  Several of the authors note that combining such disparate studies undermines confidence in their conclusions.  The five single-arm studies addressed Questions 2 and 3; this study design could not provide information on Question 1.

Overall, the quality and consistency of results of this body of evidence are weak.  Consequently, no conclusions can be drawn from this literature on how well EIBI works.  Weaknesses in research design and analysis, as well as inconsistent results across studies, undermine confidence in the reported results.  It is important to distinguish between certainty about ineffectiveness and uncertainty about effectiveness.  Based on the weakness of the available evidence, we are uncertain about the effectiveness of EIBI for ASDs.

The results for each question are summarized below.

Question 1: How effective is EIBI in improving the functioning of children with autism spectrum disorders, and how does it compare to other early intervention approaches?

The strongest evidence is provided by two randomized, controlled trials.  However, weaknesses in research design, differences in the treatments and outcomes compared, and outcomes for children with autism cannot be determined.  For example, Sallows and Graupner (2005) found that children in the experimental and control groups improved significantly over time, but there was no statistically significant difference in the rate of improvement between groups.  Smith et al. (2000), in contrast, found that the experimental group had significantly better cognitive and communication skills than the control group at follow-up, but there was no difference between the groups’ adaptive skills.

The EIBI treatments used in the two studies also varied.  For example, Sallows and Graupner compared groups receiving clinic-directed therapy for 39 hours per week in year one versus a parent-directed therapy averaging 32 hours per week.  So both groups had fairly intensive, ABA-based therapy and differed on the precise hours of treatment and the intensity of supervision by more experienced staff.  Smith et al., in contrast, compared a clinic-run program for about 25 hours per week versus special education classes for 10-15 hours per week combined with a parent training program.  The evidence is insufficient to determine whether or not EIBI is more effective than alternative approaches for children with ASDs.

Question 2: Can patient characteristics be identified that predict better outcomes from EIBI?

Given the lack of a definitive answer to Question 1 on the relative effectiveness of EIBI, Question 2 on whether there are characteristics of children that predict a greater likelihood of success cannot be answered either.  However, researchers have attempted to measure the relationship between specific characteristics and outcomes.  The ideal method of identifying characteristics likely to predict treatment outcomes is to examine treatment by covariate (i.e., child characteristics) interaction terms in the context of a randomized, controlled trial.  Such analyses can be performed for nonrandomized studies, but the evidence is weaker due to the uncertain influence of residual confounding.  Single-arm studies can suggest candidate characteristics that could be investigated in future randomized, controlled trials.  Therefore, the reported results should be interpreted with caution.  Age and cognitive functioning at intake (usually measured by IQ) were the most commonly studied characteristics in the studies included in this review.  Three of the four studies examining the impact of pretreatment cognitive functioning found that it significantly predicted outcomes, while one (a randomized, controlled trial) did not.  The findings on age were more variable, with some studies suggesting that younger age at the start of therapy is a predictor of better outcomes, while others found no difference based on initial age.

Question 3: Does the effect of EIBI vary with the intensity of treatment?

The findings on whether more intense treatment leads to better outcomes were inconsistent, and no conclusions can be drawn.  In a nonrandomized study, Lovaas and colleagues reported that outcomes were better in the more-intensive group (more than 40 hours per week versus 10 or fewer hours per week).  This study has a number of limitations, however, including lack of randomization; use of multiple instruments to measure the same outcome; and focus on IQ and school placement, while overlooking other important outcomes such as socialization and communication.  Sallows and Graupner randomized children into groups receiving about 39 versus 32 hours per week and detected no difference in outcomes across groups.  However, the variation in intensity was not as great in this study, and there were other differences in the programs as well (e.g., clinic- versus parent-directed therapy programs).

Conclusions of the Special Report Update

The variability of presentation and progression among children with ASDs, as well as potential differences in delivery of behavioral interventions, make this topic challenging to study.  Nevertheless, given the importance of caring for children with ASD, additional research is needed to identify those characteristics of treatment—content, technique, intensity, starting and ending age, etc.—that maximize its effectiveness.  Because of the challenges in launching a very large randomized trial and the ethical necessity to provide some treatment to the control group, this body of research needs to be built piece by piece, with a series of studies that investigate different components of the larger research question.  For this to be effective, however, the overall quality of studies needs to be improved, including a greater emphasis on randomized, controlled trials, where at all possible; substantially larger sample sizes; uniformity of outcomes evaluated and instruments used to measure them; and consistent treatments that do not vary widely within treatment groups (i.e., experimental or control group).

Other Treatment Modalities

RDI training is relatively new and the only published materials found were studies conducted by the developers of RDI.  The first article (Gutstein et al., 2007) describes a study that reviewed the progress of 16 children who participated in RDI between 2000 and 2005.  In the second article (Gutstein, 2009), RDI is described as “a program designed to empower and guide parents of children, adolescents and young adults with autism spectrum disorders (ASD) and similar developmental disorders to function as facilitators for their children's mental development.  RDI teaches parents to play an important role in improving critical emotional, social, and metacognitive abilities through carefully graduated, guided interaction in daily activities.” The article also states that although a controlled, blinded study of RDI has yet to be done, preliminary research suggests positive results.  Available evidence is insufficient to evaluate the effect of RDI on health outcomes; therefore, RDI is considered experimental, investigational and unproven. 

In addition, a search of peer reviewed literature through December 2010 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2013 Update

In 2012, the American Academy of Pediatrics published “Nonmedical Interventions for Children with ASD: Recommended Guidelines and Further Research Needs”, which was developed by an independent Technology Evaluation Panel based on a systematic review of scientific evidence. (Maglione et al.) In their report, they state:

“The strength of evidence of efficacy of interventions designed to address the core deficits of autism varies among approaches. However, none of the evidence reaches the level of high strength according to established standards. Additional large, well-designed controlled trials are needed; at this point, the strength of evidence for even the most-studied intervention types and approach modalities is moderate. Few head-to-head trials have compared the effects of different intervention approaches and components, so we can conclude little about the superiority of specific programs (other than pointing out that certain approaches have little or no evidence of effectiveness). Few studies are powered to identify specific program components associated with efficacy, and few follow participants long-term. In addition, few studies of interventions for pre- or nonverbal children were reported in the literature... our own guideline statements are based largely on expert opinion, with the systematic review as a starting point. Thus, recommendations may be based on a low to moderate level of evidence. To increase external validity, we only kept statements that everyone agreed or strongly agreed to...We also emphasize that not all children who attend these programs will make significant gains regarding core deficits; the scientific literature is not clear as to which individual participant characteristics are associated with success of various approaches.”

A search of literature using MEDLINE identified no studies that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

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.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90, 299.91

ICD-10 Codes

F84.0, F84.3, F84.5, F84.8, F84.9

Procedural Codes: 70450, 70460, 70470, 70496, 70551, 70552, 70553, 76390, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78647, 80100, 80103, 82016, 82017, 82127, 82128, 82131, 82136, 82139, 82379, 83015, 83825, 83655, 83918, 83919, 83921, 87230, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 90281, 90283, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90882, 90887, 90889, 90899, 92506, 92507, 92585, 92586, 95004, 95018, 95024, 95027, 95028, 95044, 95052, 95056, 95060, 95065, 95070, 95076, 95079, 95812, 95813, 95816, 95819, 95822, 95827, 95925, 95927, 95928, 95930, 95965, 95966, 95967, 96105, 96110, 96111, 96116, 96118, 96119, 96120, 96125, 96150, 96151, 96152, 96153, 96154, 96155, 97001, 97002, 97003, 97004, 97533, 99183, A4575, E1902, G0151, G0152, G0153, G0157, G0158, G0159, G0160, G0161, G0176, G0177, P2031, S8035, S9015, S9128, S9129, S9131, S9355, V5008, V5362, V5363 [Deleted 1/2013: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90857, 90862, 95010, 95015, 95075]
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History
April 2011:  No change in terms of policy - clarified language only.  
May 2011

 New CPT Codes Added: T1026, T2023, T2025

 
June 2011 Updated Full Circle service centers
October 2011 No change in policy statements, clarification on diagnosis confirmation from recognized listed centers for out-of-state members
June 2013 Added Pediatric Therapy Clinic - Billings as a recognized provider.
December 2013 Policy formatting and language revised.  Title changed from "Autistic Disorder, Coverage of Services" to "Autism Spectrum Disorders (ASD)".
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Autism Spectrum Disorders