Medical Policy

Subject: Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
Document #: BEH.00004 Current Effective Date:    03/29/2017
Status: Reviewed Last Review Date:    02/02/2017


This document addresses activity therapy (for example, music, dance, art or play therapies) when used to treat Autism Spectrum Disorders (ASDs) and Rett syndrome. ASDs, as defined in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), include disorders previously referred to as:

Note: For information on other services that may be provided for Autism Spectrum Disorders, see:

Position Statement

Investigational and Not Medically Necessary:

Activity therapy, including but not limited to music, dance, art or play therapies, is considered investigational and not medically necessary for the treatment of Autism Spectrum Disorders and Rett syndrome.


ASDs and Rett syndrome are complex and multifaceted conditions for which there is no known specific etiology, although there is evidence of a genetic etiology in ASDs. The impairments of these conditions are generally severe, and, given the uncertainty around the cause(s) of these disorders, treatments are not directed at the core pathology, but at the comorbid medical and behavioral conditions.

The use of activity therapy methodologies for the treatment of ASDs and Rett syndrome have not been studied well, and there is a lack of sufficient evidence addressing their effectiveness, safety, relevance, and/or reliability in improving the pathological manifestations of ASDs.


In May 2013, the American Psychiatric Association (APA) released the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This edition of the DSM includes several significant changes over the previous edition, including combining several previously separate diagnoses under the single diagnosis of "autism spectrum disorder." This diagnosis includes the following disorders, previously referred to as: atypical autism, Asperger's disorder, childhood autism, childhood disintegrative disorder, early infantile autism, high-functioning autism, Kanner's autism, and pervasive developmental disorder not otherwise specified. All of these conditions are now considered under one diagnosis, ASD. It should be noted that Rett is not included in the new DSM-5 ASD diagnostic group.

The DSM-5 describes the essential diagnostic features of autism spectrum disorder as both a persistent impairment in reciprocal social communication and restricted and repetitive pattern of behavior, interest or activities. These attributes are present from early childhood and limit or impair everyday functioning. Parents may note symptoms as early as infancy, and the typical age of onset is before 3 years of age. Symptoms may include problems with using and understanding language; difficulty relating to or reciprocating with people, objects, and events; lack of mutual gaze or inability to attend events conjointly; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings, and repetitive body movements or behavior patterns. Children with childhood disintegrative disorder are an exception to this description, in that they exhibit normal development for approximately 2 years followed by a marked regression in multiple areas of function.

Individuals with ASD vary widely in abilities, intelligence, and behaviors. Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development. Repetitive play skills, resistance to change in routine and inability to share experiences with others, and limited social and motor skills are generally evident. Unusual responses to sensory information, such as loud noises and lights, are also common. Children unaffected by ASDs can exhibit unusual behaviors occasionally or seem shy around others sometimes without having ASD. What sets children with ASD apart is the consistency of their unusual behaviors. Symptoms of the disorder have to be present in all settings, not just at home or at school, and over considerable periods of time. With ASD, there is a lack of social interaction, impairment in nonverbal behaviors, and a failure to develop normal peer relations. A child with an ASD tends to ignore facial expressions and may not look at others; other children may fail to respect interpersonal boundaries and come too close and stare fixedly at another person. Individuals with ASDs may require additional assessments to differentiate between ASDs and other conditions that may co-occur, such as limited intellect.

The exact causes of autism are unknown, although genetic factors are strongly implicated. A study released by the Center for Disease Control and Prevention (2014) indicates that the incidence of ASD was as high as 1 in 68.

Rett syndrome is a disorder of the nervous system that leads to regression in development, especially in the areas of expressive language and hand use. In most cases, it is caused by a genetic mutation. It occurs almost exclusively in girls and may be misdiagnosed as autism or cerebral palsy.

Seventy-five percent of Rett syndrome cases have been linked to a specific genetic mutation on the X chromosome. This gene contains instructions for creating methyl-CpG-binding protein 2 (MeCP2), which regulates the manufacture of various other proteins. Mutations in the MeCP2 gene cause these other proteins to be produced incorrectly, which damage the maturing brain. Studies link mutations in this gene. Most cases of the mutation arise spontaneously without any traceable cause. However, there also seem to be some clusters within families and certain geographic regions, for example Norway, Sweden, and Northern Italy.

A child affected with Rett syndrome normally follows a standard developmental path for the first 5 months of life. After that time development in communication skills and motor movement in the hands seems to stagnate or regress. After a short period, stereotyped hand movements, gait disturbances, and slowing of the rate of head growth become apparent. Other problems may also be associated with Rett syndrome including seizures, disorganized breathing patterns while awake and apraxia/dyspraxia (the inability to program the body to perform motor movements). Apraxia/dyspraxia is a key symptom of Rett syndrome and it results in significant functional impairment, interfering with body movement, including eye gaze and speech.

The use of various activity therapies have been investigated for the treatment of ASDs and Rett syndrome. To date, the published peer-reviewed scientific studies addressing music, dance, art and other activity therapies is weak and does not provide substantial evidence that such treatment methods consistently provide any clinically significant benefits (Bahrami, 2013, 2016; Corbett, 2016; Hildebrandt, 2016; Koehne, 2016; Srinivasan, 2015).

In 2016, Bremer and colleagues published the results of a systematic review of the literature addressing exercise interventions for children with ASDs. They identified 13 studies meeting their selection criteria. Of these studies, four addressed hippotherapy, which is not addressed in this document. The remaining nine studies involved a variety of activities including martial arts, jogging, water exercise, and yoga. The largest of these studies included 15 subjects and the smallest involved four (mean 7.63). The authors reported that exercise interventions consisting of jogging, horseback riding, martial arts, swimming, and dance or yoga may result in improvements to numerous behavioral outcomes including stereotypic behaviors, social-emotional functioning, cognition and attention. However, they conclude that future research with well-controlled designs, standardized assessments, larger sample sizes and longitudinal follow-up is necessary.


Asperger's syndrome: A developmental disorder that affects the parts of the brain that control social interaction and communications.

Autism Spectrum Disorders: A collection of associated developmental disorders that affect the parts of the brain that control social interaction and verbal and non-verbal communication.

Childhood disintegrative disorder: A developmental disorder characterized by marked regression in multiple areas of functioning following a period of at least 2 years of apparently normal development.

Rett syndrome: A developmental disorder that affects the parts of the brain that control social interaction, communications, and motor function.


The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure and diagnosis codes, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

G0176 Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)
ICD-10 Diagnosis  
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

Peer Reviewed Publications:

  1. Bahrami F, Movahedi A, Marandi SM, Abedi A. Kata techniques training consistently decreases stereotypy in children with autism spectrum disorder. Res Dev Disabil. 2012; 33(4):1183-1193.
  2. Bahrami F, Movahedi A, Marandi SM, Sorensen C. The effect of karate techniques training on communication deficit of children with autism spectrum disorders. J Autism Dev Disord. 2016; 46(3):978-986.
  3. Bremer E, Crozier M, Lloyd M. A systematic review of the behavioural outcomes following exercise interventions for children and youth with autism spectrum disorder. Autism. 2016; 20(8):899-915.
  4. Corbett BA, Key AP, Qualls L, et al. Improvement in social competence using a randomized trial of a theatre intervention for children with autism spectrum disorder. J Autism Dev Disord. 2016; 46(2):658-672.
  5. Hildebrandt MK, Koch SC, Fuchs T. "We dance and find each other"1 : effects of dance/movement therapy on negative symptoms in autism spectrum disorder. Behav Sci (Basel). 2016 Nov 10;6(4). pii: E24.
  6. Koehne S, Behrends A, Fairhurst MT, Dziobek I. Fostering social cognition through an imitation- and synchronization-based dance/movement intervention in adults with autism spectrum disorder: a controlled proof-of-concept study. Psychother Psychosom. 2016; 85(1):27-35.
  7. Srinivasan SM, Park IK, Neelly LB, Bhat AN. A comparison of the effects of rhythm and robotic interventions on repetitive behaviors and affective states of children with Autism Spectrum Disorder (ASD). Res Autism Spectr Disord, 2015; 18:51-63.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics; Committee on Children with Disabilities. The pediatrician's role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics. 2001; 107(5):1221-1226.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. Washington, DC. May 2013.
  3. Centers for Disease Control and Prevention. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010. Morbidity and Mortality Weekly Report (MMWR). 2014; 3(SS02):1-21.
  4. Geretsegger M, Elefant C, Mössler KA, Gold C. Music therapy for people with autism spectrum disorder. Cochrane Database Syst Rev. 2014; (6):CD004381.
  5. Greenspan SI, Brazelton TB, Cordero J, et al. Guidelines for early identification, screening, and clinical management of children with autism spectrum disorders. Pediatrics. 2008; 121(4):828-830. Reaffirmed April 2014.
  6. Maglione MA, Gans D, Das L, et al.; Technical Expert Panel; HRSA Autism Intervention Research – Behavioral (AIR-B) Network. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012; 130(Suppl 2):S169-S478.
  7. McPheeters ML, Warren Z, Sathe N, et al. A systematic review of medical treatments for children with autism spectrum disorders. Pediatrics. 2011; 127(5):e1312-1321.
  8. Myer SM, Johnson CP.; American Academy of Pediatrics Council on Children with Disabilities. Management of children with autism spectrum disorders. Pediatrics. 2007; 120(5):1162-1182.
  9. Volkmar F, Siegle M, Woodbury-Smith M, et al.; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2014; 53(2):237-257.
Websites for Additional Information
  1. International Rett Syndrome Association. Available at: Accessed on November 18, 2016.
  2. National Institute of Neurological Disorders and Stroke. Asperger's Syndrome - Short Summary. Available at: Accessed on November 18, 2016.
  3. National Institute of Neurological Disorders and Stroke. Pervasive Developmental Disorders. Available at: Accessed on November 18, 2016.
  4. National Library of Medicine. Medical Encyclopedia, Autism spectrum disorder. Available at: Accessed on November 18, 2016.
  5. National Library of Medicine. Medical Encyclopedia, Rett Syndrome. Available at: Accessed on November 18, 2016.
  6. The Nemours Foundation. Autism. Available at: Accessed November 18, 2016.

Activity therapy

Document History
Status Date Action
Reviewed 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed 01/20/2017 Behavioral Health Subcommittee review. Updated Rationale and Reference sections.
Revised 02/04/2016 MPTAC review.
Revised 01/29/2016 Behavioral Health Subcommittee review. Revised title and Position Statement to limit scope to activity therapy for ASDs and Rett Syndrome. Updated Description/Scope, Rationale, Background, Coding, Reference, and Index sections. Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review.
Reviewed 07/31/2015 Behavioral Health Subcommittee review. Updated Discussion and Reference sections.
Reviewed 08/14/2014 MPTAC review.
Reviewed 08/08/2014 Behavioral Health Subcommittee review. Updated Discussion and Reference sections.
Reviewed 08/08/2013 MPTAC review.
Reviewed 07/26/2013 Behavioral Health Subcommittee review. Revised title and clinical indications sections to replace "Pervasive Developmental Disorders" with "Autism Spectrum Disorders". Clarified Investigational and NMN statement regarding activity therapy. Revised Description, Discussion, and Reference sections.
  01/01/2013 Updated Coding section with 01/01/2013 CPT changes; removed codes 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90857, 90862 deleted 12/31/2012.
Reviewed 08/09/2012 MPTAC review.
Reviewed 08/03/2012 Behavioral Health Subcommittee review. Updated Reference section. Updated Coding section; removed ICD-9 procedure codes (not applicable).
Reviewed 08/18/2011 Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed 08/12/2011 Behavioral Health Subcommittee review. Updated Reference section.
Revised 08/19/2010 MPTAC review. Simplified document title. Removed all non-behavioral health-related treatments from BEH.00004 and moved them to new document: MED.00107. Updated Rationale, Background, Coding and Definitions sections.
Reviewed 05/13/2010 MPTAC review. Updated Coding and Reference sections.
Reviewed 02/21/2009 MPTAC review. Updated Reference section.
  01/01/2009 Updated Coding section with 01/01/2009 HCPCS changes; removed Q4097 deleted 12/31/2008.
Revised 07/25/2008 MPTAC review. Clarified position statements in the medically necessary section. Added use of hyperbaric oxygen therapy and chelation therapy to investigational and not medically necessary position statement. Deleted Lovaas therapy from investigational and not medically necessary position statement. Updated Rationale, Coding, and Reference sections.
  01/01/2008 Updated Coding section with 01/01/2008 HCPCS changes; removed HCPCS J1567, Q4087, Q4088, Q4091, Q4092 deleted 12/31/2007. The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Revised 08/23/2007 MPTAC review. Minor wording revision to position statement for "Interventions to improve verbal and nonverbal communication skills." Updated Reference section.
  07/01/2007 Updated Coding section with 07/01/2007 HCPCS changes; removed HCPCS J1563, J1564, Q9941, Q9942, Q9943, Q9944 deleted 12/31/2005.
Revised 09/14/2006 MPTAC review. Revised rationale; updated references.
Reviewed 03/23/2006 MPTAC review.
New 12/01/2005 MPTAC initial document development.