Medical Treatments of Autism Spectrum Disorders
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Defines medically necessary diagnostic tests and evaluates the medical necessity and investigational status of specific assessments and treatments for Autism Spectrum Disorders (ASD) for Capital Bluecross members and providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Autism Spectrum Disorders
Medically Necessary Diagnostic Testing
Diagnostic testing may be considered medically necessary to confirm a diagnosis of Autism Spectrum Disorders when appropriate to the clinical presentation.
Genetic testing selection guided by clinical features such as macrocephaly for PTEN
Investigational/Not Supported Treatments
The following assessments and treatments are considered investigational due to insufficient evidence:
These are listed as investigational due to insufficient clinical evidence
The policy lists a number of interventions whose coverage status is determined elsewhere or which are not supported as treatments for Autism Spectrum Disorders (ASD) within this document. Examples include allergy testing, event-related brain potentials, nutritional and micronutrient testing, magnetoencephalography/magnetic source imaging, cognitive rehabilitation, auditory integration training, biofeedback, chelation therapy, sensory integration therapy, vision therapy, and evaluations by speech-language pathologists. These services are either addressed by other Capital Bluecross policies or lack sufficient evidence for general coverage as ASD treatments and therefore are not endorsed here.
The following procedure and supply codes are designated as investigational in this policy: A9999 and J2850. Use of these codes may be subject to denial on the basis that the associated services are considered investigational.
Specific examples identified as investigational include secretin infusion (when used for ASD in the absence of a documented pancreatic disorder) and the use of sensory-friendly, weighted, or compression clothing. The policy notes that secretin has been studied in randomized controlled trials and a systematic review found no evidence that secretin improves core features of autism, and that sensory garments have not been thoroughly studied; therefore both are considered investigational due to insufficient clinical evidence of benefit.
Coding — Covered and Investigational Codes
| F84.0 | Autistic disorder |
| F84.2 | Rett's syndrome |
| F84.3 | Other childhood disintegrative disorder |
| F84.5 | Asperger's syndrome |
| F84.8 | Other pervasive developmental disorders |
| F84.9 | Pervasive developmental disorder, unspecified |
| A9999 | Procedure code listed as investigational |
| J2850 | Procedure code listed as investigational |
Provider Actions, Prior Authorization, and Billing Notes
Check product‑level applicability for prior authorization
This policy applies only to certain programs and products administered by Capital Blue Cross; for fully‑insured group policies, CHIP policies, and self‑funded groups that have opted to be subject to Act 62, the requirements of this policy are applied to the extent permitted by Act 62. Providers should verify product‑level prior authorization requirements before ordering services.
Codes removed from policy — prior authorization managed by Evicore (effective 07/01/2026)
Certain procedure codes have been removed from this policy and are to be managed by Evicore effective 07/01/2026; prior authorization requirements for those codes may be handled by Evicore. Providers must obtain any required prior authorization through Evicore for services using those codes.
- Removed codes are managed externally by Evicore effective 07/01/2026
- Claims using those removed codes may require prior authorization through Evicore
Follow FEP medical policy and FDA assessment rules for FEP members
For members in the Federal Employee Program (FEP), follow the FEP medical policy manual; FDA‑approved drugs, devices, or biological products are not considered investigational and may be assessed on the basis of medical necessity under the FEP program.
- Refer to the FEP medical policy manual at fepblue.org for program‑specific rules
- Pennsylvania Act 62 does not apply to FEP
No step therapy rules specified in this excerpt
No step therapy rules are specified in this policy excerpt; providers should not assume step therapy requirements are defined here and should check product‑level or program‑specific protocols if applicable.
Document comprehensive assessment elements for ASD evaluations
Assessments for ASD should include a thorough history — review of pregnancy, labor and delivery, early neonatal course, developmental, communication and motor milestones — and medical history including screening for sensory deficits (hearing/vision) and consideration of genetic evaluation where indicated (e.g., Fragile‑X, CMA).
- Document pregnancy, labor/delivery, and neonatal history
- Document developmental, communication, and motor milestones
- Screen for sensory deficits (hearing, vision) and document medical signs/symptoms relevant to genetic evaluation
- Consider and document rationale for genetic testing (e.g., CMA)
Follow policy history and updated code management processes
Administrative updates to the policy list removed and externally managed codes with their effective dates (e.g., removed codes effective 01/01/2021; codes removed for Evicore management effective 07/01/2026). Providers should follow the updated code management processes noted in the policy history.
- See policy history for specific code removals and effective dates (e.g., codes removed effective 01/01/2021, added 0263U effective 10/01/2021)
- Codes removed for external management by Evicore effective 07/01/2026
Investigational services may be denied
Services listed as investigational (for example, sensory‑friendly/compression/weighted clothing and secretin infusion when no pancreatic disorder is documented) are considered investigational and therefore may be denied.
- Sensory‑friendly, compression or weighted clothing is investigational
- Secretin infusion is investigational in the absence of a documented pancreatic disorder
Claims for codes managed by Evicore may require prior authorization
Procedure codes removed from this policy are to be managed by Evicore effective 07/01/2026; claims for services using those codes may require prior authorization through Evicore and could be denied if authorization is not obtained.
- Evicore will manage specified codes effective 07/01/2026
- Obtain prior authorization via Evicore for codes now managed externally to avoid denial
Treatment Modalities and Therapy Guidance
Speech and behavioral therapies
Appropriateness may vary by age and clinical presentation
Referenced therapies noted as investigational or reviewed
The following therapies and interventions have been referenced in the literature or prior policy history and are identified here for reference as investigational or reviewed:
These interventions lack sufficient evidence for benefit and are identified as investigational in this policy and supporting literature
Background
Autism Spectrum Disorders (ASDs) are heterogeneous neurodevelopmental conditions characterized by impairments in social communication and restricted, repetitive patterns of behavior. Diagnostic evaluation is complex and typically requires a comprehensive developmental and medical history, assessment of communication and motor milestones, and information about prenatal, perinatal, and neonatal factors. Genetic abnormalities and copy number variants are associated with autism and developmental delay; therefore genetic testing (for example chromosomal microarray or targeted testing such as fragile X) and genetic counseling may be appropriate depending on the clinical presentation.
Definitions
Revision History & References
Use policy history for recent administrative and code management changes
The policy history documents multiple administrative updates and code management changes including the April 6, 2026 administrative update that removed procedure codes for management by Evicore (effective 07/01/2026); providers must follow these updates when billing or seeking authorization.
- Multiple past administrative updates list removed/added codes and effective dates
- April 06, 2026 update removed procedure codes to be managed by Evicore effective 07/01/2026
Selected references and supporting literature cited in this policy include clinical practice guidelines and systematic reviews relevant to ASD identification, evaluation, and management. Key citations include the American Academy of Pediatrics guidance on identification and management of children with ASD, Cochrane reviews such as the evaluation of intravenous secretin for ASD, and genetic evaluation resources describing the role of chromosomal microarray and clinical genetics in identifying etiologies of developmental disorders. Other referenced works address complementary and alternative therapies and sensory-related research relevant to ASD.
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