priority health autism coverage & Prior Auth

Coverage Criteria

inv-01: Diagnosis and Evaluation Criteria

Covered when ALL of the following are met:

Diagnostic standard: Diagnosis should be consistent with the standards of the Diagnostic and Statistical Manual of Mental Disorders at the time of evaluation.

Initial evaluation for diagnostic clarification, including psychological testing, is considered medically necessary.

Multimodal assessment: Diagnostic evaluation must include caregiver reports, records (medical, school, other evaluations), collateral reports (e.g., teachers, other treatment providers), standardized psychological tools data, and an observational assessment; no single data source determines diagnosis.

Second opinion: Priority Health may require a second diagnostic opinion from a contracted, licensed PhD psychologist with specialized training in autism spectrum disorders.

inv-02: ABA Treatment Criteria

ABA treatment covered when ALL of the following are met:

Authorization source: Authorization for ABA is determined by the clinical findings and ABA indications recommended by Behavioral Health InterQual®.

Providers: access InterQual® via Priority Health Prism Authorization Criteria Lookup.

BCBA supervision: An ABA treatment plan must be supervised by a Board Certified Behavior Analyst (BCBA) who oversees the treatment and coordinates with other medical professionals as necessary.

Supervision frequency: Supervision of line staff by the BCBA must occur at a minimum of 1 hour of supervision for every 15 hours of treatment with the member.1 hour per 15 hours

Continuing stay/ongoing authorization requires documentation of measurable progress based on a treatment plan that specifically addresses Behavioral Health InterQual® criteria.

inv-03: Genetic Testing

Genetic testing coverage:

Genetic testing authorization: Medical necessity for genetic testing for Autism Spectrum Disorder is assessed according to EviCore guidelines.

Providers must access EviCore criteria via Priority Health Prism (Authorizations → Authorization Criteria Lookup).

inv-04: Application to products

Coverage is product- and benefit-specific and may require prior authorization or referral to state programs for certain members.

Product-specific application: Coverage is subject to the member's specific benefits; group-specific policy will supersede this policy when applicable. Consult the member's plan documents for HMO/EPO, POS, PPO, ASO, INDIVIDUAL, MEDICARE, and MEDICAID/HEALTHY MICHIGAN PLAN variations.

See Priority Health Provider Manual and plan documents for product-specific rules.

Prior authorization and referrals: Certain services may require prior authorization; for Medicaid/Healthy Michigan Plan members, evaluation, diagnostic testing, and treatment services are managed through Michigan's Department of Community Mental Health.

For Medicare members, services for ASD may not be covered per CMS determinations; consult plan/manual.

inv-05: Medical necessity and experimental treatment review

Medical necessity review and exceptions

Prior authorization and documentation: When prior authorization is required, providers must submit documentation demonstrating that the requested drug, service, or procedure is medically necessary.

Refer to the Priority Health Provider Manual for submission requirements.

Investigational/experimental treatments: Individual case review may allow coverage for investigational yet promising treatments with prior plan approval; all determinations for experimental, investigational, or unproven treatments will be made by a Priority Health medical director or clinical pharmacist.

Exceptions may be considered for terminal illness or chronic, life‑threatening, severely disabling disease causing clinical deterioration.

inv-06: Medicaid/Healthy Michigan Plan management

State-managed programs

Michigan Medicaid and Healthy Michigan Plan: Evaluation, diagnostic testing, and treatment services for autism spectrum disorders for Priority Health Medicaid and Healthy Michigan Plan members are managed through Michigan's Department of Community Mental Health.

Coverage for these members follows Michigan Medicaid rules and the Michigan Medicaid Provider Manual as applicable.

Services that are the legal responsibility of a school program are excluded from coverage. This includes evaluations completed in an educational setting. Also excluded are services provided by family or household members. Providers should not bill Priority Health for school-responsible educational evaluations or for services furnished by family/household members, as these are outside the plan’s coverage scope.

The following procedure codes are explicitly excluded from coverage regardless of diagnosis and will be denied if billed: 0362T, 0373T, and S8940.

For Priority Health Medicare members, evaluation, diagnostic testing, and treatment services for autism spectrum disorders are not covered by the health plan. Providers should refer Medicare members to plan documents or CMS guidance for applicable benefits and billing rules.

Treatments that are not supported by scientific evidence for core ASD deficits are considered not medically necessary or excluded. Examples called out in the policy include equine-assisted activities/therapies (e.g., hippotherapy, therapeutic riding), as well as other nonstandard interventions such as music therapy, yoga, and massage. These modalities are not supported for treatment of core autism spectrum disorder deficits and are excluded when billed for ASD treatment.

Coding (ICD-10, CPT, HCPCS)

ICD-10 Codes that may support medical necessityICD-10

F84.0	Autistic disorder
F84.5	Asperger's syndrome
F84.8	Other pervasive developmental disorders
F84.9	Pervasive developmental disorder, unspecified

ABA CPT CodesCPTCovered

97151	Behavior identification assessment, by a physician or other qualified healthcare professional, per 15 minutes
97152	Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes
97153	Adaptive behavior treatment by protocol, per 15 minutes; administered by technician under the direction of a BCBA, face-to-face with one patient
97154	Group adaptive behavior treatment by protocol, per 15 minutes; administered by technician under the direction of a BCBA, face-to-face with two or more patients
97155	Adaptive behavior treatment with protocol modification, per 15 minutes; administered by BCBA, which may include simultaneous direction of technician
97156	Family adaptive behavior treatment guidance, per 15 minutes; administered by BCBA, with or without patient present, face-to-face with guardian(s)/caregiver(s)
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional, face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

Psychotherapy CPT CodesCPTCovered

90832	Psychotherapy, 30 minutes with patient
90833	Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834	Psychotherapy, 45 minutes with patient
90836	Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837	Psychotherapy, 60 minutes with patient

Speech Therapy CPT/HCPCS CodesmixedCovered

92521	Evaluation of speech fluency (e.g., stuttering, cluttering)
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression (e.g., receptive and expressive language)
92524	Behavioral and qualitative analysis of voice and resonance
S9152	Speech therapy, re-evaluation
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

Speech therapy CPT/HCPCSCPTCovered

92521	Evaluation of speech fluency (e.g., stuttering, cluttering)
92522	Evaluation of speech sound production (e.g., 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
S9152	Speech therapy, re-evaluation
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

Physical & Occupational therapy CPTCPTCovered

97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care
97110	Therapeutic procedure, therapeutic exercises, each 15 minutes
97112	Therapeutic procedure, neuromuscular reeducation, each 15 minutes

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Behavioral health testing CPTCPTCovered

96110	Developmental screening, with interpretation and report, per standardized instrument
96112	Developmental test administration; first hour
96113	Developmental test administration; each additional 30 minutes
96116	Neurobehavioral status exam; first hour
96121	Neurobehavioral status exam; each additional hour
96130	Psychological testing evaluation services; first hour
96131	Psychological testing evaluation services; each additional unit
96132	Neuropsychological testing evaluation services; first hour
96133	Neuropsychological testing evaluation services; each additional hour
96136	Psychological or neuropsychological test administration and scoring by professional; first 30 minutes

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Codes not covered regardless of diagnosisCPTNot Covered

0362T	Behavior identification supporting assessment, each 15 minutes (not covered)
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes (not covered)
S8940	Equestrian/hippotherapy, per session (not covered)

Provider Actions & Authorization Requirements

Prior Authorization

Genetic Testing Prior Authorization

Prior authorization required for genetic testing. Genetic testing for ASD is managed per EviCore guidelines; providers must follow the EviCore prior authorization pathway when requesting genetic testing services.

Follow EviCore prior authorization process via Priority Health Prism
Submit documentation per EviCore requirements to demonstrate medical necessity

Documentation Required

ABA Authorization & Continued Authorization Documentation

ABA authorization and continued authorization documentation. ABA authorization is determined by clinical findings and Behavioral Health InterQual® recommendations. Continued stay/renewal requests must include documentation showing measurable progress based on a treatment plan that specifically addresses Behavioral Health InterQual® criteria.

ABA treatment plan must be supervised by a BCBA who coordinates with other treating professionals

Applied Behavior Analysis (ABA) Coverage & Supervision

inv-33: ABA Coverage and Supervision

ABA-specific requirements

Prior authorization: ABA treatment services require prior authorization and are reviewed per Behavioral Health InterQual® criteria.

Access InterQual® via Priority Health Prism Authorization Criteria Lookup.

Service settings: ABA services may be provided in center, office, or home settings; prior authorization is required for services in any setting.

Staffing and supervision: Treatment plans must be supervised by a BCBA who oversees care and coordinates with other medical professionals as necessary.1 hour per 15 hours

BCBA must provide a minimum of 1 hour supervision per 15 hours of ABA treatment.

Treatment Modalities and Exclusions

inv-34: Equine-assisted activities and therapies (EAAT/hippotherapy/THR)

EAAT coverage stance: Equine-assisted activities and therapies (EAAT/hippotherapy/therapeutic riding) are considered unproven for treatment of core ASD deficits and are listed among treatments not supported; coverage is not recommended for ASD treatment based on current evidence.

Refer to cited guidance (e.g., AAP) and internal exclusions.

inv-35: Equine-assisted activities

Equine-assisted activities not covered: Equine-assisted activities/therapies billed with code S8940 (Equestrian/hippotherapy, per session) are not covered regardless of diagnosis.

Billing for S8940 will be denied.

Visit Limits and Continuation Criteria

Visit limits and continued authorization

Continued authorization conditionContinued authorization for ABA services requires documentation demonstrating measurable progress based on a treatment plan that specifically addresses Behavioral Health InterQual® criteria.

Visit limitsNo explicit visit limits are stated in the policy.

Supervision requirement linked to authorizationABA treatment plans must be supervised by a BCBA who oversees treatment and coordinates with other medical professionals.

Context for InterQual® accessTo access InterQual® guidelines: Log into Priority Health Prism → Authorizations → Authorization Criteria Lookup.

Background

Autism spectrum disorder (ASD) is characterized by persistent deficits in social communication and interaction and by restricted, repetitive patterns of behavior that begin in early development. Prevalence estimates cited in the evidence base approximate 1 in 36 children aged 8 years (CDC 2020). The policy references guideline and review literature informing evaluation and treatment recommendations, noting that evidence for several complementary or nonstandard interventions is conflicting and does not support these therapies for core ASD deficits.

Definitions & References

Equine-assisted activities and therapies (EAATs) — definition

Definition of EAATsEquine-assisted activities and therapies (EAATs) are animal-assisted interventions using horses intended to improve social and behavioral skills; includes hippotherapy (clinical use by OTs/PTs/SLPs to engage sensory/neuromotor/cognitive systems) and therapeutic horseback riding (instruction-focused activities).

Hippotherapy (HIP)A clinical equine-assisted intervention involving manipulation of equine movement by OTs, PTs, or SLPs to engage sensory, neuromotor, and cognitive systems for functional outcomes (e.g., balance, sensory processing).

Therapeutic Horseback Riding (THR)Equine-assisted activity combining horseback riding and nonriding barn activities taught by a licensed instructor targeting physical, behavioral, and prosocial health.

Evidence and guidance sourcesPolicy cites AAP guidance, CDC prevalence data, systematic reviews, and Michigan MDHHS guidelines among references evaluating EAATs and ASD interventions.

Cited literature and references

OpenPayer

Autism Spectrum Disorders (diagnosis, genetic testing, ABA)