Autism Spectrum Disorder (ASD) — Medical Coverage Policy
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Defines medical necessity, covered assessments, behavioral treatments (including ABA), and lists services considered experimental or not covered for assessment and treatment of autism spectrum disorder (ASD) for Baylor Scott & White Health Plan members.
No material clinical or coverage changes in this revision.
Coverage Criteria for ASD Assessment and Treatment
inv-01: Assessment considered medically necessary
BSWHP may consider certain procedures and services medically necessary for the assessment of ASD when ANY of the following are present:
inv-02: Services considered medically necessary for assessment when triggers met
When the above criterion is met, BSWHP may consider the following evaluations as medically necessary:
inv-03: Intensive behavioral treatment for established ASD
For patients with an established diagnosis of ASD, BSWHP may consider intensive behavioral health treatment as medically necessary when ALL of the following are met:
inv-04: Not Covered / Experimental Services for ASD
Experimental, investigational, or unproven services and codes listed below are NOT covered when billed for the treatment of autism spectrum disorders:
Applies specifically when used for treatment of ASD; services may have other indications outside ASD not addressed here.
BSWHP considers a broad set of procedures and services experimental, investigational, or unproven and NOT covered when used for the assessment or treatment of autism spectrum disorder (ASD). Examples from the policy include laboratory and specialty tests (e.g., allergy testing, heavy metal testing, mitochondrial testing, micronutrient testing, hair analysis, stool analysis, urinary peptide testing), advanced neurophysiologic or imaging modalities (e.g., magnetoencephalography, event-related potentials, MEG, and certain neuroimaging studies), and diverse alternative or unproven therapies (e.g., stem cell therapy, cannabidiol/CBD or cannabis-based therapies, oxytocin, suramin infusion). This list is not exhaustive; the policy states these items are not covered because they are considered experimental, investigational, or unproven for ASD.
BSWHP does NOT cover the use of general consumer electronic devices for ASD assessment or treatment. Devices specifically named as not covered include, but are not limited to, computers, smartphones, personal digital assistants (PDAs), and tablet devices (e.g., iPads), as these devices are considered not medical in nature for the purposes of ASD care.
BSWHP does NOT cover genetic screening for ASD in the general population. The policy states such screening is considered not medically necessary and of unproven benefit; medically indicated genetic testing (e.g., CMA, fragile X, MECP2 when appropriate) is addressed separately and may require prior authorization per the Genetic Testing Policy (Policy 037).
The policy explicitly lists CPT and HCPCS/J-codes that are considered experimental, investigational, or unproven and NOT covered when billed for ASD treatment. Examples include CPT codes for immune globulin administration and biofeedback (e.g., 90281, 90283, 90284, 90875, 90876, 90901, 97532, 97533, 97810–97813) and HCPCS/J-codes for hyperbaric oxygen and immune globulin products and other items (e.g., A4575, C1300, G0176, J1459, J1557, J1559, J1561, J1562, J1566, J1568, J1569, J1572, J1599, J2850, S8940). These codes will be denied when billed for ASD treatment per the policy.
BSWHP specifies that neuropsychological testing is NOT covered as a routine component of ASD assessment. Providers should refer to Baylor Scott & White Healthcare Guidelines, Policy #224, for coverage criteria and authorization requirements for neuropsychological testing when clinically indicated.
The policy lists numerous examples of interventions considered experimental/unproven and not covered for ASD, including but not limited to: immune globulin therapies and related J-/CPT codes, hyperbaric oxygen therapy and associated device/procedure codes (e.g., A4575, C1300, 99183), acupuncture (CPT 97810–97813), equestrian/hippotherapy (S8940), secretin infusion (J2850), chelation therapy, auditory integration therapy, sensory integration therapy, music and art therapies, craniosacral/chiropractic manipulation, and many nutritional or supplement-based interventions. These interventions are identified in the policy as experimental, investigational, or unproven for ASD and therefore not covered.
Codes and Diagnostic References
| 0362T | Adaptive behavior treatment by protocol |
| 0373T | Adaptive behavior treatment by protocol |
| 97151 | Adaptive behavior treatment interventions |
| 97152 | Adaptive behavior treatment interventions |
| 97153 | Adaptive behavior treatment interventions |
| 97154 | Adaptive behavior treatment interventions |
| 97155 | Adaptive behavior treatment interventions |
| 97156 | Adaptive behavior treatment interventions |
| 97157 | Adaptive behavior treatment interventions |
| 97158 | Adaptive behavior treatment interventions |
| 96116 | Neurobehavioral status exam, per hour |
| 96118 | Neuropsychological testing, per hour |
| 96119 | Neuropsychological testing administered by technician, per hour of technician time |
| 96120 | Neuropsychological testing administered by computer, with interpretation |
| 82705 | Fat or lipids, feces; qualitative |
| 83018 | Heavy metal; quantitative, each |
| 83615 | Lactate dehydrogenase (LD) (LDH) |
| 86001 | Allergen specific IgG quantitative or semiquantitative, each allergen |
| 86003 | Allergen specific IgE; quantitative or semiquantitative, each allergen |
| 86005 | Allergen specific IgE; qualitative, multiallergen screen |
| 90281 | Immune globulin (Ig), human, for intramuscular use |
| 90283 | Immune globulin (IgIV), human, for intravenous use |
| 90284 | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each |
| 90875 | Individual psychophysiological therapy incorporating biofeedback training by any modality; approximately 20-30 minutes |
| 90876 | Individual psychophysiological therapy incorporating biofeedback training by any modality; approximately 45-50 minutes |
| 90901 | Biofeedback training by any modality |
| 92065 | Orthoptic and/or pleoptic training, with continuing medical direction and evaluation |
| 97532 | Development of cognitive skills to improve attention, memory, problem solving; direct (one-on-one) patient contact by the provider, each 15 minutes |
| 97533 | Sensory integrative techniques to enhance sensory processing; direct (one-on-one), patient contact by the provider, each 15 minutes |
| 97810 | Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes |
| A4575 | Topical hyperbaric oxygen chamber, disposable |
| C1300 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval |
| E1902 | Communication board, non-electronic augmentative or alternative communication device |
| G0176 | Activity therapy, such as music, dance, art or play therapies not for recreation, related to care/treatment of disabling mental health problems, per session (45 minutes or more) |
| J1459 | Injection, immune globulin (Privigen), intravenous, non-lyophilized, 500 MG |
| J1557 | Injection, immune globulin (Gammaplex), intravenous, 500 mg |
| J1559 | Injection, immune globulin (Hizentra), 100 mg |
| J1561 | Injection, immune globulin (Gamunex), intravenous, 500 mg |
| J1562 | Injection, immune globulin (Vivaglobin), 100 mg |
| J1566 | Injection, immune globulin, intravenous, lyophilized, 500 mg |
| F84.0-F84.9 | Autism spectrum disorder |
Provider Responsibilities, Prior Authorization, and Billing
Prior authorization and genetic testing note
Prior authorization is Not Applicable at the policy header level; however, all genetic testing referenced (including CMA, fragile X, and MECP2 where indicated) is subject to prior authorization and documentation requirements per Genetic Testing Policy 037. Providers must verify plan-specific EOC/SPD for any additional prior authorization rules.
- Policy header: PRIOR AUTHORIZATION: Not Applicable
- Genetic testing (CMA, fragile X, MECP2) is subject to prior authorization per Genetic Testing Policy 037; documentation requirements apply
Prior authorization applicability
The document-level prior authorization statement for this policy is 'Not Applicable.' Providers should still confirm any plan- or product-level requirements by reviewing the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD).
- PRIOR AUTHORIZATION: Not Applicable (policy header)
- Verify EOC/SPD for plan-specific requirements
Provider actions for ASD assessment and treatment requests
When requesting assessment or intensive behavioral health services for ASD, include the clinical indications, applicable evaluations, and—when applicable—a formal documented treatment plan with family training and education. Verify plan exclusions for behavioral training or educational services before providing or billing for ABA or similar services.
- Include clinical evaluation/assessment details (medical history, developmental screening, behavioral health, SLP/OT/PT, audiology, EEG/neuroimaging as indicated).
- For intensive behavioral treatment, submit a formal plan that documents the provider, supervision, expected measurable improvement, and family training/education.
- Check the applicable benefit plan contract for exclusions of behavioral training or educational services (e.g., ABA).
Step therapy / policy history
No step therapy requirements are specified in this policy excerpt. Policy history and prior updates are recorded in the policy history section but do not establish step therapy rules.
- Policy history documents prior reviews and updates; no step therapy rules present in this excerpt.
Documentation required with intensive behavioral health treatment requests
Requests for intensive behavioral health treatment must include a formal documented plan that demonstrates identified interventions, expected meaningful and measurable improvement, and family training and education to assure interventions are carried out.
- Plan must specify provider type (licensed/certified behavioral health professional or BCBA/BCaBA under appropriate supervision, continuous presence).
- Plan must document expected measurable improvement and include family training and education.
Plan / plan-product billing note
Providers should bill services to the appropriate Baylor Scott & White Health Plan product or plan as applicable (see organizational/plan ownership note) and confirm product-specific billing rules and coverage in the member's EOC/SPD.
- HMO, PPO/EPO, self-funded plan distinctions and ownership are described in the note—bill to the applicable BSWHP product.
- Confirm plan/product-specific coverage and billing instructions in the member's EOC/SPD.
Behavioral training/educational services may be excluded — verify member benefits
Services that are behavioral training or educational in nature (for example, applied behavioral analysis) may be excluded by some benefit plans; if the applicable benefit plan contract contains such exclusions, claims for those services may be denied.
- Check the member's benefit plan contract for exclusions of therapy for learning disabilities, developmental delays, autism, or services considered educational/training in nature.
- If exclusions exist, ABA and similar behavioral training services are not covered and may be denied.
Denial risk for experimental/unproven services listed as not covered
Services and products listed as 'Experimental, Investigational, Unproven NOT Covered when used for the treatment of autism spectrum disorders' (including the specified CPT, HCPCS, and J-codes) will be denied when billed for ASD treatment.
- The policy lists specific CPT codes (e.g., 90281, 90875, 97533, 97810), HCPCS (e.g., A4575, G0176, S8940) and J-codes for immune globulin and secretin that are considered experimental/unproven for ASD.
- These services are not covered for the treatment of ASD and will be denied when billed for that indication.
Level-of-Care and Treatment Setting Criteria
inv-29: Outpatient / Intensive behavioral health
Level of care guidance for outpatient / intensive behavioral health services:
Applied Behavior Analysis (ABA) Coverage Criteria
inv-30: ABA coverage criteria — state-mandated and policy criteria relevant to ABA coverage
State-mandated requirements and policy criteria relevant to Applied Behavior Analysis (ABA) coverage:
inv-31: ABA and allied therapies (related modalities)
Evidence-based and allied therapies relevant to ASD treatment:
Permitted and Excluded Treatment Modalities
inv-32: Activity therapy, Hyperbaric Oxygen, Equestrian/Hippotherapy — experimental/unproven grouping
The following modalities are listed as experimental/unproven and are NOT covered when used for ASD:
These determinations apply specifically to ASD treatment; services may have other indications outside ASD.
Limits and Financial Maximums
Key Definitions
Background and Rationale
Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction and by restricted, repetitive patterns of behavior. The policy emphasizes early, individualized, evidence-based interventions (for example, applied behavior analysis, developmental behavioral approaches, speech and occupational therapies) and recognizes that ASD commonly co-occurs with conditions such as intellectual disability, anxiety, ADHD, epilepsy, and sleep or gastrointestinal problems. The document also notes FDA-approved medications for irritability associated with ASD (e.g., risperidone, aripiprazole) and describes the DSM-5-TR consolidation of prior ASD-related diagnoses into a single spectrum with severity levels based on support needs.
Policy Revision History
Updated diagnostic framework to DSM-5-TR; expanded screening criteria and assessment tools; added genetic testing (CMA, fragile X, MECP2) with cross-reference to Policy 037; replaced blanket PKU screening with targeted metabolic testing; broadened EEG indications; added BCBA/BCaBA as qualifying ABA providers; expanded prescribing authority to treating physician; softened neuropsychological testing exclusion with cross-reference to Policy 224; added five experimental/unproven exclusions (TMS, stem cell, CBD, oxytocin, suramin); updated prevalence data to 2020 ADDM; added federal MHPAEA/parity language; restructured Texas mandate and added Category III code annotation for 0362T/0373T.
Removed 'Medicare NCD or LCD specific InterQual criteria may be used when available.'
Policy reviewed with no changes noted.
Corrected the 'For Medicaid Plans' section to specify use of this Medical Policy when TMPPM lacks medical necessity guidance.
Policy reviewed; formatting changes and added hyperlinks to NCD and TMPPM; beginning and ending note sections updated to align with CMS requirements and business entity changes.
Policy reviewed; language added to include First Care; no substantive changes.
Policy reviewed; language added to include First Care; minor update deleting an extraneous comment in Overview.
Policy entry with initial content and subsequent review history beginning on this date.
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