Medical Policy



Subject: Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
Document #: MED.00107 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses pharmacotherapeutic, medical, and clinical rehabilitative treatments and therapies used to treat Autism Spectrum Disorders (ASDs) and Rett syndrome. Behavioral health interventions, such as psychological and psychiatric therapies are not addressed in this document.

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: Please see the following related documents for additional information related to ASDs:

Position Statement

Medically Necessary:

Speech therapy interventions to improve verbal and nonverbal communication skills for individuals with Autism Spectrum Disorders and Rett syndrome are considered medically necessary when criteria for speech therapy are met.

Physical and occupational therapy for comorbid physical impairments for individuals with Autism Spectrum Disorders and Rett syndrome are considered medically necessary when criteria for physical and occupational therapy are met.

Medical therapy for the treatment of irritability or other conditions associated with ASD is considered medically necessary when indicated.

Investigational and Not Medically Necessary:

The following treatments or therapies are considered investigational and not medically necessary for the treatment of Autism Spectrum Disorders and Rett syndrome:

  1. Elimination diets (for example, gluten and milk elimination); and
  2. Facilitated communication; and
  3. Nutritional supplements (for example, megavitamins, high-dose pyridoxine and magnesium, dimethylglycine); and
  4. Pet therapy; and
  5. Secretin infusion; and
  6. Spinal manipulation; and
  7. Vision therapy.
Rationale

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 both ASD and Rett syndrome. 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. There is a wide array of medical, pharmacological, and other treatments proposed for the treatment of ASDs. For the vast majority of these treatment methods, there is a lack of scientific evidence regarding their effectiveness, safety, relevance, and/or reliability in improving the pathological manifestations of ASDs. The above noted medically necessary treatments have validity as components of treating ASD-associated comorbidities, and are evidence-based. Those treatments deemed Investigational and Not Medically Necessary lack sufficient evidence as to their effectiveness, safety, relevance, and/or reliability in improving the pathological manifestations of ASDs.

Background/Overview

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 disorders 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.

Children 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.

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 treatment of ASDs may take many different approaches, focusing on one or more aspects of the condition being treated. There is no single treatment that has consistently demonstrated benefit at the core symptoms of these disorders. Treatments/interventions (such as speech and language therapy) are of greatest potential benefit in the pre-school child and of very limited value in the older child/adolescent, so that the age of the child is also a factor in determining the appropriateness and necessity of a given treatment. Medications can play a role in the management of some behavioral symptoms of autism spectrum disorder. For example, risperidone and aripiprazole are U. S. Food and Drug Administration (FDA) approved for the treatment of irritability.

A wide variety of medical, pharmacological and other treatments have been proposed for the treatment of ASDs. Unfortunately for the vast majority of them there is a lack of scientific evidence demonstrating any significant health or behavioral benefits.

Definitions

Asperger's syndrome: A developmental disorder that affects the parts of the brain that control social interaction and communications. Asperger's is no longer considered a separate condition, but is now considered within the ASD group of conditions based upon the DSM-5 criteria.

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 (CDD): A developmental disorder characterized by marked regression in multiple areas of functioning following a period of at least 2 years of apparently normal development. CDD is no longer considered a separate condition, but is now considered within the ASD group of conditions based upon the DSM-5 criteria.

Educational Interventions: Learning interventions that assist children with obtaining knowledge, communication through speech, sign language, writing and other methods and social skills (NOTE: Many benefit contracts exclude coverage for services that are educational in nature).

Elimination diets: A proposed treatment for autism spectrum disorders involving specialized diets that omit specific foods or food groups such as gluten and milk.

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

Secretin infusion: A proposed treatment to pervasive developmental delay syndromes involving the injection/infusion of the hormone secretin into the body.

Vision therapy: A proposed treatment for autism spectrum disorders that involves focusing an individual's attention on a single visual stimulus in an attempt to improve their attention span and ability to mentally focus their attention.

Coding

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 Medically Necessary:

CPT  
  Services may include, but are not limited to, the following:
92507-92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder [includes codes 92507, 92508]
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 (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524 Behavioral and qualitative analysis of voice and resonance
   
HCPCS  
S9152 Speech therapy, re-evaluation
   
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

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.

CPT  
98925-98929 Osteopathic manipulative treatment (OMT) [includes codes 98925, 98926, 98927, 98928, 98929, when specified as manipulation of spinal regions]
98940-98942 Chiropractic manipulative treatment (CMT); spinal [includes codes 98940, 98941, 98942]
   
HCPCS  
E1399 Durable medical equipment, miscellaneous [when specified as facilitated communication devices]
J2850 Injection, secretin, synthetic, human, 1 microgram
   
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
   
References

Peer Reviewed Publications:

  1. Dawson G, Rogers S, Munson J, et al. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010; 125(1):e17-e23.
  2. Gutstein, SE, Burgess AF, Montfort K. Evaluation of the relationship development intervention program. Autism. 2007; 11(5):397-411.
  3. Howard JS, Sparkman CR, Cohen HG, et al. A comparison of intensive behavior analytic and eclectic treatments for young children with autism. Res Dev Disabil. 2005; 26(4):359-383.
  4. Levy SE, Souders MC, Wray J, et al. Children with autistic spectrum disorders. I: comparison of placebo and single dose of human synthetic secretin. Arch Dis Child. 2003; 88(8):731-736.
  5. Rossignol DA. Hyperbaric oxygen therapy might improve certain pathophysiological findings in autism. Med Hypotheses. 2007a; 68(6):1208-1227.
  6. Rossignol DA, Rossignol LW, James SJ, et al. The effects of hyperbaric oxygen therapy on oxidative stress, inflammation, and symptoms in children with autism: an open-label pilot study. BMC Pediatr. 2007b; 7(1):36.
  7. Rossignol DA, Rossignol LW, Smith S, et al. Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind, controlled trial. BMC Pediatr. 2009; 13(9):21.
  8. Sheinkopf SJ, Siegel B. Home-based behavioral treatment of young children with autism. J Autism Dev Disord. 1998; 28(1):15-23.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Child and Adolescent Psychiatry. Policy Statement: Secretin in the Treatment of Autism. June 15, 2002. Available at: http://www.aacap.org/aacap/policy_statements/2002/Secretin_in_the_Treatment_of_Autism.aspx. Accessed on May 25, 2017.
  2. 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.
  3. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators; Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders--autism and developmental disabilities monitoring network, 14 sites, United States, 2002. MMWR Surveill Summ. December 18, 2009; 58(SS10):1-20.
  4. Canadian Pediatric Society Position Statement. Early intervention for children with autism. Pediatr Child Health. 2004; 9(4):267-277.
  5. 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. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm?s_cid=ss6302a1_w. Accessed on May 25, 2017.
  6. Ching H, Pringsheim T. Aripiprazole for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;(5):CD009043.
  7. 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.
  8. Hirsch LE, Pringsheim T. Aripiprazole for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2016;(6):CD009043.
  9. Hurwitz R, Blackmore R, Hazell P, et al. Tricyclic antidepressants for autism spectrum disorders (ASD) in children and adolescents. Cochrane Database Syst Rev. 2012;(3):CD008372
  10. James S, Montgomery P, Williams K. Omega-3 fatty acids supplementation for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;(11):CD007992.
  11. James S, Stevenson SW, Silove N, Williams K. Chelation for autism spectrum disorder (ASD). Cochrane Database Syst Rev. 2015:(5):CD010766.
  12. Mahajan R, Bernal MP, Panzer R, et al.; Autism Speaks Autism Treatment Network Psychopharmacology Committee. Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism spectrum disorders. Pediatrics. 2012; 130(Suppl 2):S125-S138.
  13. Malow BA, Byars K, Johnson K, et al.; Sleep Committee of the Autism Treatment Network. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics. 2012; 130(Suppl 2):S106-S124.
  14. 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. Available at: http://www.pediatrics.org/cgi/content/full/120/5/1162. Accessed on May 25, 2017.
  15. New York State Department of Health Early Intervention Program. Clinical Practice Guideline Report of the Guideline Recommendations – Autism / Pervasive Developmental Disorders – Assessment and Intervention For Young Children (Age 0-3 Years). Available at: http://www.health.ny.gov/community/infants_children/early_intervention/autism/index.htm#Table_of_Contents. Accessed on May 25, 2017.
  16. Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low-birth-weight infants. Cochrane Database Syst Rev. 2015;(3):CD010061.
  17. Rueda JR, Guillén V, Ballesteros J, et al. L-acetylcarnitine for treating fragile X syndrome. Cochrane Database Syst Rev. 2015:(5):CD010012.
  18. Volkmar F, Siegel 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.
  19. Williams K, Brignell A, Randall M, et al. Selective serotonin reuptake inhibitors (SSRIs) for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2013;(8):CD004677.
  20. Williams K, Wray JA, Wheeler DM. Intravenous secretin for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;(4):CD003495.
Websites for Additional Information
  1. International Rett Syndrome Association. Avalable at: http://www.rettsyndrome.org. Accessed on May 25, 2017.
  2. National Institute of Neurological Disorders and Stroke. Asperger's Syndrome - Short Summary. Available at: http://www.ninds.nih.gov/disorders/Asperger/Asperger.htm. Accessed on May 25, 2017.
  3. National Institute of Neurological Disorders and Stroke. Pervasive Developmental Disorders. Available at: http://www.ninds.nih.gov/disorders/pdd/pdd.htm. Accessed on May 25, 2017.
  4. National Library of Medicine. Medical Encyclopedia, Autism. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm. Accessed on May 25, 2017.
  5. National Library of Medicine. Medical Encyclopedia, Rett Syndrome. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001536.htm. Accessed on May 25, 2017.
  6. The Nemours Foundation. Pervasive Developmental Disorders. Available at: http://kidshealth.org/parent/medical/learning/pervasive_develop_disorders.html. Accessed on May 25, 2017.
Index

Alternative communication
Augmentative communication aids
Autism
Chelation therapy
Discrete trial training
Globulin infusion

Document History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed 07/21/2017 Behavioral Health Subcommittee review. Updated References section.
Revised 08/04/2016 MPTAC review.
Revised 07/29/2016 Behavioral Health Subcommittee review. Revised MN statement regarding medical therapy. Removed INV and NMN indications that are addressed on other documents. Updated Definitions and Reference sections. Updated Coding section and removed ICD-9 codes. 
Revised 08/06/2015 MPTAC review.
Revised 07/31/2015 Behavioral Health Subcommittee review. Clarified investigational and not medically necessary statement regarding pet therapy. Updated Reference section. Updated Coding section; removed S8940 equestrian therapy addressed in another document.
  01/26/2015 Updated Coding section with 01/01/2015 HCPCS changes; removed C1300 deleted 12/31/2014.
Reviewed 08/14/2014 MPTAC review.
Reviewed 08/08/2014 Behavioral Health Subcommittee review. Updated Description/Scope, Rationale, and Reference sections.
  01/01/2014 Updated Coding section with 01/01/2014 CPT and HCPCS changes; removed 92506, C9130 deleted 12/31/2013.
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". Revised Description, Discussion, and Reference sections.
  04/01/2013 Updated Coding section with 04/01/2013 HCPCS changes.
  01/01/2013 Updated Coding section with 01/01/2013 CPT and HCPCS descriptor changes.
Reviewed 08/09/2012 MPTAC review.
  04/01/2012 Updated Coding section; HCPCS J1557 replaced C9270 effective 01/01/2012.
Reviewed 08/18/2011 MPTAC review.
  01/01/2011 Updated Coding section with 01/01/2011 HCPCS changes.
New 08/19/2010 MPTAC review. Initial document development. Moved non-behavioral health treatments from BEH.00004 to new document. Added spinal manipulation to Investigational and Not Medically Necessary section. Updated Coding section to include 10/01/2010 HCPCS changes.