Medical Treatments of Autism Spectrum Disorders
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Defines medical necessity, investigational services, and covered diagnostic testing and procedure codes for evaluation and treatment of Autism Spectrum Disorders for Capital Blue Cross products where this policy applies.
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 ASD when appropriate clinically:
Exact clinical indications and sequencing may be further detailed in the cross-referenced genetic testing policies.
Investigational Assessments and Treatments
The following assessments and treatments are considered investigational due to insufficient evidence:
Randomized trials and systematic reviews have not demonstrated benefit of secretin for core autism features; sensory/weighted/compression clothing lack sufficient study.
Other evaluations and interventions listed in this policy (for example, chelation therapy, auditory integration training, sensory integration therapy, vision therapy, biofeedback, nutritional/micronutrient testing, event‑related brain potentials, magnetoencephalography/magnetic source imaging, cognitive rehabilitation, allergy testing, and similar services) are governed by their respective medical policies. Medical necessity determinations for these services are made using the criteria set forth in those specific policies and are not authorized under this policy unless the applicable policy criteria are met.
Procedures billed using procedure codes A9999 and J2850 are designated as investigational in this policy. Claims using these codes for treatments of autism spectrum disorders may be subject to non‑coverage or denial and require verification of any prior authorization requirements with the payer.
The policy identifies the use of secretin infusion (in the absence of documented pancreatic disorders) and the use of sensory‑friendly, weighted or compression clothing for ASD as investigational due to insufficient evidence that they improve core features of autism. A systematic review of randomized trials found no evidence that secretin improves core autism features, and sensory‑friendly/weighted/compression garments have not been thoroughly studied for ASD treatment.
Coding Tables and Code History
| 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 |
Provider Actions, Documentation, and Billing
Verify product-specific coverage and prior authorization
Verify that the member’s specific Capital Blue Cross product and benefit plan includes coverage for services under this policy and determine whether prior authorization is required for the requested service; this policy is applicable only to certain programs and products and is subject to product variations.
- Policy applies only to certain Capital Blue Cross programs and products.
- For fully-insured, CHIP, and self-funded groups subject to Act 62, requirements applied as permitted by Act 62; FEP program follows FEP Medical Policy Manual.
Investigational code prior authorization (A9999, J2850)
Confirm prior authorization requirements for services billed with codes A9999 and J2850 because these procedure codes are identified as investigational in the policy; verify whether the payer requires prior authorization for investigational services before scheduling or billing.
Confirm applicable medical necessity criteria and cross-references
Ensure clinical assessments and requested services meet the specific medical necessity criteria in the applicable Capital Blue Cross policy before submission; follow cross-referenced policies for services governed elsewhere.
- Other services (e.g., chelation therapy, auditory integration training, sensory integration therapy, vision therapy, biofeedback, nutritional/micronutrient testing) are governed by their respective medical policies and require those policies' criteria.
- Diagnostic testing is covered when it meets the medical necessity criteria listed in this policy.
Apply product-specific exclusions and program distinctions
Check the member’s benefit language for product-specific exclusions or variations (including FEP and CHIP distinctions) and apply those stipulations when determining coverage and authorization.
- FEP program follows FEP Medical Policy Manual and may assess FDA-approved products on medical necessity basis.
- Product applicability and benefit variations are described in Section II (Product Variations).
Required clinical documentation for ASD evaluation
Provide a thorough ASD evaluation record including prenatal, perinatal and developmental history, communication and motor milestones, medical history with screening for sensory deficits, and documentation of signs suggestive of genetic syndromes.
- Review of pregnancy, labor, delivery, and early neonatal course.
- Developmental history including communication and motor milestones.
- Medical history including screening for hearing or visual impairments and discussion of conditions such as Fragile-X syndrome.
Ensure coding aligns with the latest policy coding table
Use the policy’s current coding table when selecting procedure codes; align claims coding with the most recent policy coding updates and history to avoid miscoding.
- Policy history documents coding updates and reviews; providers should ensure coding aligns with the latest policy coding table.
- Refer to the Covered Procedure Codes list (e.g., 96130–96139, 96146, neuropsych and genetic testing codes) in the coding section when applicable.
Denial risk for investigational or cross‑referenced services
Do not submit services listed as investigational or those governed by other policies as medically necessary without meeting the applicable policy criteria; such claims may be denied.
- Services listed as investigational or addressed by other specific medical policies may be denied if submitted as medically necessary under this policy.
- Secretin infusion and sensory/weighted/compression clothing are specifically identified as investigational in this policy.
Background on Autism Spectrum Disorders
Autism spectrum disorders are heterogeneous neurodevelopmental conditions with no single known etiology. Diagnosis is complex and typically requires a thorough clinical history — including prenatal and neonatal history, developmental milestones (communication and motor), medical history, and screening for sensory deficits and features suggestive of genetic syndromes — to guide appropriate diagnostic testing and management.
Definitions and Clinical Resources
Behavioral and Applied Behavior Analysis (ABA) Considerations
Behavioral and Therapeutic Considerations
Therapies for individuals with ASD may include educational, behavioral, and/or psychological interventions; appropriateness varies by age and symptom profile.
Providers should individualize therapy based on age and clinical presentation.
Treatment Modalities and Alternative Therapies
Alternative/Complementary Therapies
These therapies are designated investigational in this policy.
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