CG-MED-75 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

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:

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.

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

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.

Note: the following services are considered not medically necessary for the treatment of ASDs:

In May 2013, the American Psychiatric Association (APA) released the 5^th 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 (Baio, 2018) indicates that the incidence of ASD was as high as 1 in 59.

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.

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 Not Medically Necessary lack sufficient evidence as to their effectiveness, safety, relevance, and/or reliability in improving the pathological manifestations of ASDs.

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.

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

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

Subject: Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
Guideline #: CG-MED-75	Publish Date: 07/08/2020
Status: Reviewed	Last Review Date: 05/14/2020

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

Status	Date	Action
Reviewed	05/14/2020	Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, References and Websites sections.
Reviewed	06/06/2019	MPTAC review. Updated Description, References and Websites sections.
New	07/26/2018	MPTAC review. Initial document development. Moved content of MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome to new clinical utilization management guideline document with the same title.