Cigna Autism Assessment & Treatment Policy Update

Coverage Criteria for ASD Assessment and Treatment

inv-01: Assessment - Medical Necessity

Assessment services are considered medically necessary when a suspected or known ASD is present and ANY of the following red-flag criteria are met:

Red-flag developmental criteria: Any loss of any language or social skills at any age OR absence of babbling by 12 months OR absence of gesturing (e.g., pointing, waving bye-bye) by 12 months OR absence of single word speech by 16 months OR absence of 2-word spontaneous (not echolalic) phrases by 24 months.see thresholds

Supports ordering of behavioral health evaluation and listed assessments

Assessment services considered medically necessary: Behavioral health evaluation including psychiatric examination; autism-specific developmental screening (CPT 96110; CPT 96112/96113); evaluation by speech-language pathologist; occupational and/or physical therapy evaluation when motor deficits, motor planning, or sensory dysfunction are present; electroencephalogram (EEG) when there is suspicion of a seizure; lead screening; quantitative plasma amino acid assays to detect phenylketonuria; neuroimaging when candidate for specific interventions such as epilepsy surgery.

See coding lists for specific CPT/CPT-like codes and EEG code descriptions

inv-02: Treatment - Behavioral Health Medical Necessity

Behavioral health treatment (e.g., behavior modification, family therapy, cognitive behavioral therapy or other psychotherapy) for ASD is considered medically necessary when ALL of the following are met:

Behavioral health treatment criteria: 1) Individual meets DSM-5-TR criteria for ASD; 2) Services are appropriate in type, frequency, extent, site and duration and are provided by an appropriate behavioral health care professional; 3) Meaningful and measurable improvement is expected from the therapy.

Refer to Intensive Behavioral Interventions policy (ABA) for ABA-specific criteria; see related coverage policies for speech, neuropsychological testing, OT/PT

inv-03: Medically necessary services for ASD

Considered medically necessary for treatment of ASD when applicable policy criteria are met.

Medically necessary procedure groups: Psychotherapy codes (90832, 90834, 90837 and associated add-on E/M codes 90833, 90836, 90838) and interactive complexity (90785) when the behavioral health treatment criteria are satisfied; occupational therapy evaluation codes (97165, 97166, 97167) when documentation supports the indicated complexity level; listed assessment and evaluation services when clinical criteria met.

See coding lists for full covered assessment/evaluation codes and for codes considered not medically necessary

inv-04: Not medically necessary / Not covered services

The following services/codes are considered not medically necessary, not covered, educational/not reimbursable for ASD assessment or treatment.

Imaging and diagnostic tests not supported: Magnetic source imaging and magnetoencephalography (MEG) (eg, S8035, 95965-95967) are considered not medically necessary for ASD assessment; unlisted procedure code for nervous system (64999) when used to report TMS is not medically necessary.

See list of not-covered diagnostic codes

Immune and hyperbaric therapies not supported: Intravenous immune globulin (IVIG) products and related injection codes (eg, 90283, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572) and hyperbaric oxygen therapy codes (eg, 99183, G0277) are considered not medically necessary for ASD treatment.

Refer to CP 5026 for IVIG policy

Chelation and related services: Chelation therapy and home infusion chelation services (eg, S9355) and provocative chelation testing lack evidence and are not supported for routine ASD care.

Testing codes and chelation services are listed among not-covered items

inv-05: Indicated diagnostic testing

Testing and assessment covered when clinically indicated:

Indication-based diagnostic testing: EEG is appropriate when clinical history or exam suggests seizures, atypical regression, or other neurologic concern; metabolic testing, immune testing, environmental toxin testing, and neuroimaging are appropriate only when specific clinical features suggest these evaluations (eg, suspected metabolic disorder, autoimmune disease, lead exposure, or candidate for epilepsy surgery).

Routine baseline EEG or routine metabolic/environmental testing without indication is discouraged

inv-06: Tests lacking sufficient evidence

Not supported / insufficient evidence:

Unsupported routine tests: Routine use of metabolomic panels (eg, NPDX ASD), broad metabolic panels, hair/blood/urine environmental toxin screening, provocative chelation tests for mercury, and many proposed metabolomic or unvalidated laboratory panels lack sufficient evidence for routine diagnostic use in ASD.

These tests are not supported for routine ASD assessment absent specific, documented clinical indications

inv-07: Therapeutic interventions

Treatment coverage stance:

Behavioral interventions, including early intensive behavioral interventions (EIBI/IBI/ABA), parent training, and other evidence-based behavioral therapies, are supported for improving some outcomes and are considered appropriate when individualized to the patient's age and needs; refer to the Intensive Behavioral Interventions policy for specific ABA criteria and authorization.

Programs described as intensive (15–40 hours/week) in some studies; clinical response varies and should be monitored

Pharmacologic interventions for targeted symptoms: Medications do not treat core ASD features; antipsychotics such as risperidone and aripiprazole have RCT evidence for reducing irritability and challenging behaviors and may be used when those symptoms cause significant impairment, with monitoring for adverse effects.

Pharmacologic treatment should be targeted to specific interfering behaviors; see drug policy references

inv-08: Evidence-based coverage summary

Summary of evidence-based coverage considerations

Antipsychotics with evidence for targeted symptoms: Risperidone and aripiprazole have RCT evidence showing improvement in irritability and related behavioral symptoms; risperidone is FDA-approved for irritability in autistic children/adolescents.

Adverse effects (weight gain, somnolence, hyperprolactinemia, extrapyramidal symptoms) should be monitored

Medications with insufficient or low-certainty evidence: Agents such as acetylcholinesterase inhibitors, memantine, D-cycloserine, and many other pharmacologic candidates have low- or very-low-certainty evidence for improvement in core ASD symptoms and are not supported for routine use for core features.

See referenced systematic reviews and Cochrane analyses

Allied health and behavioral evidence summary: Behavioral and allied health interventions (CBT for anxiety in higher-functioning individuals, parent training, early intensive behavioral interventions) show possible benefits for specific outcomes, but evidence quality is heterogeneous and long-term benefits and generalizability vary across studies.

Services that are primarily educational or training in nature are not covered or reimbursable for ASD assessment or treatment. Examples include education and achievement testing (including IQ testing) and educational interventions such as classroom environmental manipulation or academic skills training. Related billing codes for training/educational services and school-based IEP services (e.g., G0177, H2027, S9445, S9446, T1018) are identified as educational/not covered. Additionally, multi-purpose consumer electronic devices (e.g., PDAs, tablets, smartphones) are not medical in nature and are considered not medically necessary (E1399).

The policy identifies several treatment modalities as not covered or not medically necessary for ASD when used for core ASD treatment or without medical justification. Listed non-covered therapies include art therapy, BioMat, equestrian/hippotherapy, holding therapy, music therapy, recreational therapy, and vision therapy. Activity therapies billed under activity therapy or equestrian therapy codes (e.g., G0176, H2032, S8940) are considered educational/recreational and not reimbursable for ASD treatment per this policy.

Specific diagnostic tests and certain experimental metabolomic panels are not supported for routine ASD assessment. Examples called out include blood metabolite and central carbon metabolite testing such as the NPDX ASD panels and related CPT/revenue codes (e.g., 0063U, 0263U, 0322U), and hair analysis (P2031). Magnetoencephalography (MEG) and magnetic source imaging are also listed as not medically necessary for ASD assessment (95965–95967; S8035). The policy notes limited clinical utility and insufficient peer-reviewed evidence to support these tests for general ASD diagnosis.

Provocative chelation tests for mercury and routine broad heavy metal testing are not supported for ASD assessment in the absence of specific clinical indications. The document states there is insufficient evidence in peer-reviewed literature to support provocative chelation testing for mercury and that routine testing for heavy metals or environmental toxins (hair, blood, urine) is not supported except when specific clinical history (eg, lead exposure) or neurologic concerns warrant testing.

Chelation therapy, hyperbaric oxygen therapy (HBO/HBOT), and immunotherapy/IVIG are described as unsupported by high-quality evidence for treatment of ASD and have documented safety concerns. The policy references systematic reviews and AAP guidance concluding that pharmaceutical chelation lacks evidence of benefit and carries risks (eg, hypocalcemia, renal impairment). Hyperbaric oxygen trials are preliminary and inconclusive, and IVIG evidence is of low quality and insufficient to support routine use. These interventions are cautioned against and may be considered not medically necessary absent strong supporting data.

Revision details list multiple prior policy statements that were removed. Removed items include: audiological evaluation; medical evaluation; allergy testing; celiac antibody testing; erythrocyte glutathione peroxidase studies; event-related potentials (evoked potential studies); heavy metal testing; immunologic or neurochemical abnormalities testing; intestinal permeability studies; micronutrient testing (eg, vitamin levels); provocative chelation tests for mercury; stool analysis; urinary peptides testing; acupuncture; auditory integration therapy; cognitive rehabilitation; craniosacral therapy; dietary and nutritional interventions (eg, elimination diets, vitamins); EEG biofeedback/neurofeedback; facilitated communication; secretin infusion; social skills training; Theory of Mind cognitive model; weighted blanket/mattress technology.

Magnetoencephalography (MEG) and several other listed assessment/treatment modalities are identified as not medically necessary or not covered for ASD. MEG codes (95965–95967) and magnetic source imaging (S8035) are considered not medically necessary for assessment. Transcranial magnetic stimulation reporting with unlisted nervous system code (64999) is noted as not medically necessary when used for TMS in autism; related procedural codes and devices are not supported for routine ASD treatment.

Transcranial magnetic stimulation (TMS) and related procedure coding are not supported for ASD in this policy. The policy specifically notes TMS reported with unlisted procedure code 64999 is considered not medically necessary for autism, and lists hyperbaric and immune-related procedure codes (eg, G0277, 99183, J1459–J1572) among codes considered not medically necessary for treatment of ASD. Use of these codes for TMS or for unsupported interventions may result in denial.

Routine broad metabolic panels and unvalidated metabolomic tests lack sufficient evidence for routine use in ASD assessment. The policy states the yield of routine metabolic testing is low and not recommended for regular use, and that metabolomics panels (eg, NPDX ASD) have insufficient evidence to support clinical utility for general ASD diagnosis. Hair, blood, or urine screening for environmental toxins or heavy metals is not supported except when clinically indicated (eg, suspected lead exposure).

The policy cautions against interventions that lack sufficient evidence of efficacy and/or pose safety concerns. Examples highlighted include chelation therapy, hyperbaric oxygen therapy, and immunotherapy/IVIG, which have limited or low-quality evidence and known adverse events. Provocative chelation testing, broad environmental toxin screening, and unvalidated metabolomic diagnostics are also described as unsupported for routine use and may be associated with patient risk or unnecessary interventions.

Coding Guidance and Related Criteria

Considered Medically Necessary / Listed assessment and evaluation codesmixedCovered

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
92524	Behavioral and qualitative analysis of voice and resonance
95705	Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; unmonitored
95706	EEG without video; with intermittent monitoring and maintenance

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Considered Medically Necessary for treatment (selected psychotherapy/interactive codes)CPTCovered

90785	Interactive complexity (List separately)
90832	Psychotherapy, 30 minutes with individual
90833	Psychotherapy, 30 minutes with individual when performed with an evaluation and management service (add-on)
90834	Psychotherapy, 45 minutes with individual
90836	Psychotherapy, 45 minutes with individual when performed with an evaluation and management service (add-on)
90837	Psychotherapy, 60 minutes with individual
90838	Psychotherapy, 60 minutes with individual when performed with an evaluation and management service (add-on)

Occupational therapy evaluation codesCPTCovered

97165	OT evaluation, low complexity
97166	OT evaluation, moderate complexity
97167	OT evaluation, high complexity

Considered Not Medically Necessary / Not Covered / Educational / Not ReimbursablemixedNot Covered

S8035	Magnetic source imaging (Not M N for assessment)
64999	Unlisted procedure, nervous system (Not M N for TMS)
90283	Immune globulin (IgIV), human, IV
99183	Physician attendance for hyperbaric oxygen therapy
G0277	Hyperbaric oxygen under pressure, full body chamber
J1459	Privigen injection, IV
J1556	Bivigam injection, 500 mg
J1557	Gammaplex injection, 500 mg
J1561	Gamunex-C/Gammaked injection, 500 mg
J1566	IGIV, lyophilized, 500 mg

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Red-flag developmental milestones — triggers for ASD assessment

Absence of babbling by 12 monthsConsidered a red-flag developmental milestone prompting assessment for ASD

Absence of gesturing by 12 monthsExamples: pointing, waving bye-bye — triggers further evaluation

Absence of single-word speech by 16 monthsLack of single words at 16 months is a red flag for ASD assessment

Absence of 2‑word spontaneous phrases by 24 monthsTwo-word spontaneous (non‑echolalic) phrases absent by 24 months warrants formal assessment

Any loss of language or social skills at any ageAny regression in language or social skills is a red flag and should prompt evaluation

Provider Actions, Prior Authorization, and Documentation Requirements

Billing Rule

Use appropriate codes and follow benefit plan terms

Coverage determinations require review of the member's benefit plan terms, applicable laws/regulations, and relevant collateral materials (including Cigna Coverage Policies). When submitting claims, providers must use the most appropriate and current codes. Claims submitted without covered code(s) under the applicable Coverage Policy will be denied as not covered.

Claims without covered diagnosis/procedure codes will be denied as not covered
Use current, appropriate CPT/HCPCS/ICD-10 codes as of date of submission

Prior Authorization

Psychotherapy / interactive complexity authorization

When psychotherapy is provided with interactive complexity, ensure the interactive complexity add-on code (90785) is reported in addition to the primary psychotherapy code when criteria are met. Verify prior authorization/authorization requirements per the member's benefit plan and behavioral health provisions if applicable.

Background and Scope

This policy addresses assessment and treatment services for Autism Spectrum Disorder (ASD) and Pervasive Developmental Disorders (PDD). It describes criteria for medically necessary assessment (eg, behavioral health evaluation when red-flag developmental milestones are present), behavioral health treatment medical necessity requirements (DSM-5-TR diagnosis, appropriate service parameters, and expectation of measurable improvement), and identifies services considered not medically necessary, educational/not reimbursable, or unsupported by evidence. The policy also cross-references related Cigna policies for intensive behavioral interventions, speech therapy, occupational and physical therapy, and guidance on specialized testing and interventions.

Definitions and Key Terms

Medically necessary behavioral health treatment — definition and applicability

DefinitionBehavioral health treatment for ASD includes psychotherapy (eg, behavior modification, family therapy, CBT) provided by an appropriate behavioral health professional when DSM-5-TR criteria for ASD are met

Applicability — service appropriatenessServices must be appropriate in type, frequency, extent, site, and duration for the individual

Expected outcomeTreatment must be expected to produce meaningful and measurable improvement documented by the treating professional

Cross-referencesRefer to related Cigna policies for ABA, neuropsychological testing, speech therapy, speech generating devices, occupational and physical therapy for specific criteria

Autism Spectrum Disorder (ASD) — definition and core features

Level of Care Criteria and Service Settings

Treatment Modalities — Coverage and Evidence

inv-59: Psychotherapy / Behavioral Health Treatment

Psychotherapy medical necessity: 1) DSM-5-TR diagnosis of ASD; 2) Services are appropriate in type, frequency, extent, site and duration and provided by an appropriate behavioral health professional; 3) Meaningful and measurable improvement is expected.

Applies to behavior modification, family therapy, CBT, and other psychotherapy modalities

inv-60: Psychotherapy / Activity therapies

Activity therapies guidance: Activity therapies (music, dance, art, play) and recreational therapies are generally considered educational/not covered (eg, G0176, H2032, S8940) unless a clear medical justification meeting policy criteria is documented.

Cochrane review notes low-certainty evidence for music therapy on some short-term outcomes; AAP does not support music therapy for core deficits

inv-61: Pharmacologic, CBT, Behavioral interventions

Visit Limits and Service Intensity

Intensive behavioral interventions — program intensity and visit‑limit note

Program intensity rangeIntensive behavioral intervention programs are described as 15–40 hours per week

Authorization/visit limitsNo specific visit limits or authorization windows are provided in the referenced document chunks; refer to the Intensive Behavioral Interventions policy (CP 0499) for authorization details

Program goalsFocus on improving adaptive behavior, communication/language, cognitive function, and reducing problem behaviors through individualized, intensive approaches

Revision History and Policy Changes

2026-05-15focused_reviewLatest

Focused review reported; no clinical policy statement changes noted.

2025-12-15annual_review

Annual review noted no clinical policy statement changes.

2025-01-15annual_review

Annual review removed numerous prior policy statements (including audiological evaluation; medical evaluation; allergy testing; celiac antibody 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) and removed several treatment-specific 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); also added a policy statement for electronic devices.

OpenPayer

Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment