CurrentCignaPolicy N/A

Assessment and treatment services for autism spectrum disorders (ASD) / pervasive developmental disorders (PDD)

Cigna coverage policy for assessment and treatment services for autism spectrum disorders (ASD) / pervasive developmental disorders (PDD), including what assessment and treatment services are considered medically necessary, not medically necessary, or not covered/reimbursable, and references to related coverage resources and clinical background. This part covers assessment, treatment (behavioral health), exclusions, screening, diagnostics background, and health equity considerations.

Policy Summary

PayerCigna

PolicyAssessment and treatment services for autism spectrum disorders (ASD) / pervasive developmental disorders (PDD)

Policy CodePolicy N/A

Change TypeAnnual review revisions (added electronic devices; multiple removals/revisions)

Effective Date

Next Review Date

Key ActionProviders must submit services with covered diagnosis and/or procedure codes and use the most appropriate codes as of the service date; claims without covered codes will be denied as not covered.

POLICY UPDATE CHANGES

Added policy statement for electronic devices

Removed multiple policy statements for specific tests and evaluations (audiological evaluation, medical evaluation, allergy testing, celiac antibodies testing, erythrocyte glutathione peroxidase studies, event-related potentials, heavy metal testing, immunologic or neurochemical abnormalities testing, intestinal permeability studies, micronutrient testing, provocative chelation tests for mercury, stool analysis, urinary peptides testing)

Removed policy statements including acupuncture, auditory integration therapy, cognitive rehabilitation, craniosacral therapy, dietary and nutritional interventions, EEG biofeedback/neurofeedback, facilitated communication, secretin infusion, social skills training, Theory of Mind cognitive model, weighted blanket/mattress technology

Focused review revised policy statements and previously removed policy statement for electronic devices

Multiple

Coverage Summary

This policy addresses coverage for the assessment and treatment of Autism Spectrum Disorder (ASD) and related pervasive developmental disorders, covering what services are considered medically necessary, not medically necessary, or not covered/reimbursable. It applies to Cigna-administered health benefit plans and references the DSM-5 TR as the diagnostic standard for ASD determination.

Covered populations include individuals with suspected or known ASD across the lifespan who meet applicable clinical criteria; assessment services (for example behavioral health evaluation, autism-specific developmental screening, EEG when seizure is suspected, lead and phenylalanine testing, occupational/physical therapy evaluations, and targeted neuroimaging) and behavioral health treatments are considered when policy clinical criteria are met.

The policy’s high-level purpose is to define which diagnostic assessments, evaluations, and behavioral treatments (including Intensive Behavioral Interventions where separate criteria apply) are eligible for coverage when clinical criteria and documentation requirements are satisfied, and to identify interventions and tests that lack sufficient evidence for coverage. Annual revisions to the policy (including additions such as electronic devices) are documented in the revision history.

ASD policy quick thresholds and metadata

ThresholdsAbsence of babbling by 12 months; absence of gesturing by 12 months; absence of single word speech by 16 months; absence of 2‑word spontaneous phrases by 24 months

Clinical standardDSM-5 TR

ScopeCigna coverage policy for assessment and treatment services for autism spectrum disorders (ASD), including what services are medically necessary, not medically necessary, or not covered/reimbursable

StatusCURRENT

Medical Necessity — Assessment

Medical Necessity — Treatment

Not Medically Necessary

Not Covered / Primarily Educational

Coding

Referenced CPT codes for autism-specific developmental screeningCPTCovered

96110	Autism-specific developmental screening (e.g., CHAT, PDDST-II)
96112	Developmental testing; extended (first hour)
96113	Developmental testing; interpretation/report (each additional 30 minutes)

Assessment codes considered medically necessary when policy criteria are metmixedCovered

83655	Lead
84030	Phenylalanine (PKU), blood
90791	Psychiatric diagnostic evaluation
90792	Psychiatric diagnostic evaluation with medical services
92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production; with evaluation of language comprehension and expression

Medically Necessary - Assessment and Evaluation codesCPT|HCPCS|mixedCovered

92524	Behavioral and qualitative analysis of voice and resonance
95705	EEG without video, 2-12 hours; unmonitored
95706	EEG without video, 2-12 hours; with intermittent monitoring
95707	EEG without video, 2-12 hours; with continuous real-time monitoring
95711	VEEG 2-12 hours; unmonitored
95712	VEEG 2-12 hours; with intermittent monitoring
95713	VEEG 2-12 hours; with continuous real-time monitoring
95717	EEG continuous recording, review, analysis, 2-12 hours; without video
95718	EEG continuous recording, review, analysis, 2-12 hours; with video (VEEG)
95812	EEG extended monitoring; 41-60 minutes

1–10 of 19

1/2

Medically Necessary - Treatment/Psychotherapy codesCPT|mixedCovered

90785	Interactive complexity (add-on)
90832	Psychotherapy, 30 minutes
90833	Psychotherapy, 30 minutes with E/M (add-on)
90834	Psychotherapy, 45 minutes
90836	Psychotherapy, 45 minutes with E/M (add-on)
90837	Psychotherapy, 60 minutes
90838	Psychotherapy, 60 minutes with E/M (add-on)

Not Medically Necessary - AssessmentHCPCS|CPT|miscNot Covered

S8035

Magnetic source imaging (Not Medically Necessary for assessment of ASD)

Not Medically Necessary - TreatmentCPT|HCPCS|J-codes|mixedNot Covered

64999	Unlisted procedure, nervous system (Not Medically Necessary when used to report transcranial magnetic stimulation for autism)
99183	Physician attendance and supervision of hyperbaric oxygen therapy
G0277	Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
J1459	Injection, immune globulin (Privigen), IV, 500 mg
J1556	Injection, immune globulin (Bivigam), 500 mg
J1557	Injection, immune globulin (gammaplex), 500 mg
J1561	Injection, immune globulin (Gamunex-C - Gammaked), 500 mg
J1566	Injection, immune globulin, IV, lyophilized, 500 mg
J1568	Injection, immune globulin (Octagam), 500 mg
J1569	Injection, immune globulin (Gammagard liquid), 500 mg

1–10 of 12

1/2

Educational / Not Covered / Not ReimbursableHCPCS|CPT|mixedNot Covered

G0177	Training and educational services related to care and treatment of disabling mental health problems
H2027	Psychoeducational service, per 15 minutes
S9445	Individual education, non-physician provider, per session
S9446	Individual education, non-physician provider, group, per session
T1018	School-based individualized education program (IEP) services, bundled

Not Covered / Not Reimbursable - Multi-purpose consumer devices & testsHCPCS|CPT|PLANot Covered

E1399	Durable medical equipment, miscellaneous (multi-purpose general consumer electronic devices)
83516	Immunoassay for analyte other than infectious agent antibody or antigen; qualitative or semiquantitative, multiple step method
95965	Magnetoencephalography (MEG) spontaneous brain magnetic activity
95966	MEG for evoked magnetic fields, single modality
95967	MEG for evoked magnetic fields, each additional modality
0063U	Neurology (autism), 32 amines by LC-MS/MS, plasma, algorithmic metabolic signature
0263U	Neurology (ASD), quantitative measurements of 16 central carbon metabolites, LC-MS/MS, plasma
0322U	Neurology (ASD), quantitative measurements of 14 acyl carnitines and microbiome-derived metabolites, LC-MS/MS, plasma
P2031	Hair analysis (excluding arsenic)
90283	IVIG human for intravenous use

1–10 of 14

1/2

Procedures / therapies discussed (evidence summaries only, not listing as covered here)mixed

No codes listed

Provider Actions

Documentation Required

Use appropriate codes and documentation for covered services

Use appropriate CPT, HCPCS, ICD-10, and other codes and supporting documentation when submitting claims for covered services. Ensure documentation supports the medical necessity of the service, the provider type, date(s) of service, specific procedures performed, assessment findings, treatment plan, patient progress, and any coordination with other services. Meet applicable policy statements for coverage.

Prior Authorization

Check benefit plan terms and state mandates

Check the member's benefit plan terms, coverage limits, and any state-specific mandates prior to providing services. Some states require coverage for screening, diagnosis, and treatment of autism spectrum disorder (ASD)/pervasive developmental disorder (PDD); plan terms may vary. Verify whether services are administered under the medical benefit, behavioral health benefit, or pharmacy benefit and whether prior authorization is required.

Background & Evidence

Autism Spectrum Disorder is a developmental disability with variable presentation characterized by impairments in social communication and restricted, repetitive behaviors; symptoms are present in the early developmental period though may be identified later. Early identification and intervention are associated with more positive outcomes than later or no treatment, and screening in primary care (including autism-specific tools at ~18 and 24 months) is recommended by pediatric guidance.

Routine metabolic testing has a low yield and is not recommended as regular use; novel metabolomic/blood-metabolite panels (for example, proprietary LC-MS/MS metabotype tests) and central carbon metabolites tests are noted in the policy but are considered not covered when used for ASD assessment due to insufficient evidence.

EEG is indicated only when clinically warranted (for example, suspicion of seizures, atypical regression, or other neurologic signs) and is not recommended as a routine baseline evaluation in the absence of clinical concern.

There is insufficient evidence to support testing for heavy metals (including provocative chelation tests for mercury) and routine testing of hair, blood, or urine for environmental toxins outside of lead screening; such heavy metal testing is not supported by peer-reviewed literature for ASD assessment.

Many complementary and alternative medicine (CAM) and allied health interventions (e.g., acupuncture, hyperbaric oxygen, chelation, IVIG, certain auditory and sensory integration therapies, equestrian therapy, music therapy, and numerous other listed interventions) lack adequate, consistent evidence of benefit for core ASD symptoms and are therefore not supported for routine coverage or are explicitly listed as not medically necessary or not covered. The policy documents systematic review findings that behavioral interventions have variable evidence with some benefit for certain outcomes, while pharmacologic options address associated challenging behaviors rather than core symptoms.

Evidence source	Key takeaway
AHRQ systematic reviews	Behavioral interventions (including early intensive/ABA-based programs) show some benefit for cognitive and language outcomes but evidence quality and long-term generalizability are variable
AHRQ (Weitlauf et al., 2014)	Moderate-strength evidence for early intensive ABA-based interventions improving IQ/cognitive and language; low strength for adaptive behavior, symptom severity, social skills
Daniolou et al., 2022 (meta-analysis)	Early interventions showed positive effects for cognitive ability, daily living skills and motor skills overall, but after excluding unblinded studies benefits remained for daily living and motor skills only
Deb et al., 2023 (antipsychotics)	Risperidone and aripiprazole RCTs show benefit for irritability/behavioral symptoms but with notable adverse effects (weight gain, somnolence, etc.)
CAMP metabotype finding (Smith et al., 2019)	Amino acid dysregulation metabotype identified in ~16.7% of ASD cohort with 96.3% specificity within the ASD cohort
Evidence summary / Cochrane and other reviews	Mixed/insufficient evidence for many pharmacologic and CAM interventions (e.g., memantine, D-cycloserine, hyperbaric oxygen, IVIG, chelation); music therapy may have probable short-term benefit but certainty is low
AAP guidance and diagnostic testing comments	Routine metabolic testing has low yield; EEG recommended only if clinical concern for seizures; no routine heavy metal or broad immune testing without specific indication
NPDX / novel metabolic tests (policy discussion)	Proprietary metabolomic panels (e.g., NPDX/CAMP-related assays) are discussed but such tests are listed as not covered / not reimbursable for ASD assessment in policy
Focused review / Revision notes (annual review)	Policy updates include addition of electronic devices statement and removal of multiple specific testing/evaluation policy statements per 1/15/2025 revision

Revision History

12/03/2023revised

Focused review revised policy statements and previously removed policy statement for electronic devices

1/15/2025removed

Policy Summary

PayerCigna

PolicyAssessment and treatment services for autism spectrum disorders (ASD) / pervasive developmental disorders (PDD)

Policy CodePolicy N/A

Change TypeAnnual review revisions (added electronic devices; multiple removals/revisions)

Effective Date

Next Review Date

On This Page

Documentation Required

Behavioral treatment medical necessity documentation

For behavioral health treatments, document that the individual meets DSM-5-TR criteria for ASD, that services are appropriate in type, frequency, extent, site and duration, that services are provided by an appropriately licensed behavioral health professional, and that meaningful and measurable improvement is expected. Include baseline measures, treatment goals, progress notes, and justification for the chosen modality (e.g., psychotherapy, ABA where applicable).

Denial Risk

Claims for listed Not Covered/Not Medically Necessary codes may be denied

Claims submitted with codes listed as Not Covered or Not Medically Necessary in this policy (for example services considered primarily educational, training, experimental, or other excluded items) may be denied. Ensure documentation and coding align with covered indications and policy criteria to reduce denial risk.

ASD: Autism Spectrum Disorder — a developmental disorder defined by DSM-5 TR criteria, including persistent deficits in social communication and interaction, restricted/repetitive behaviors, symptoms present in early development, and clinically significant impairment.

Not Medically Necessary: Services or procedures that the policy deems not medically necessary for assessment or treatment of ASD for the indicated purpose; examples include magnetoencephalography (MEG) for assessment and chelation therapy, hyperbaric oxygen, immune globulin, and transcranial stimulation for treatment when used for ASD.

Intensive Behavioral Interventions: Intensive Behavioral Interventions (IBI/EIBI/ABA) — comprehensive, individualized early intervention programs delivered at high intensity (typically 15–40 hours/week) aimed at improving cognitive, language, adaptive behavior and reducing problem behaviors; specific medical necessity criteria for ABA are addressed in the Intensive Behavioral Interventions policy referenced by this coverage policy.