PANS/PANDAS Form

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PANS/PANDAS - Medical Policy
Updated Revision Effective: February 1, 2025 Policy Number:

UM917POL

Approval Date: 12/29/2023

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a clinical diagnosis given to children who have a rapid onset of neuropsychiatric symptoms which may include obsessions/compulsions or food restriction. They are often diagnosed with obsessive-compulsive disorder (OCD) or an eating disorder, but the sudden onset of symptoms separates PANS from these other disorders. Children affected may also have symptoms of depression, irritability, anxiety, or difficulty with schoolwork. The cause of PANS is unknown in most cases, but is thought to be triggered by infections, metabolic disturbances, and other inflammatory reactions.

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) is a clinical diagnosis given to children who have an acute onset of neuropsychiatric symptoms, usually OCD or tics, and test positive for a recent streptococcal infection, such as strep throat. Like PANS patients, they also may suffer from uncontrollable emotions, irritability, anxiety and loss of academic ability and handwriting skills. Although PANDAS was identified as a medical syndrome more than a decade before PANS, it has now been classified as a subset of PANS (1). Streptococcal infection may be diagnosed from a throat culture, or later from an anti-strep antibody titer (ASO titer).

 Line of Business

Commercial:
Refer to criteria under Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. There are no MassHealth guidelines for the treatment of PANS/PANDAS.

Medicare:
Refer to criteria under Policy section in this medical policy. Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for the treatment of PANS/PANDAS.

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Policy

I. Coverage of assessment and treatment of PANS and PANDAS.

A. HNE covers assessment and treatment of PANS and PANDAS commensurate with available evidence and legislative requirements as set by Massachusetts Senate Bill 2984 and Chapter 260, Acts of 2020 of Massachusetts General Laws. Per this referenced mandate, HNE provides coverage for the treatment and diagnosis of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS). This includes treatment with intravenous immunoglobulin (IVIG) therapy.

B. Available treatments for PANS/PANDAS include Antibiotics, Cognitive Behavioral Therapy with or without SSRI for OCD/OCD-like symptoms, and psychopharmacological interventions for tics. Other treatments with some data to support use in treatment for PANS/PANDAS include total plasma exchange (TPE or apheresis) and IVIG.

C. Covered services per Massachusetts Senate Bill 2984 and Chapter 260, Acts of 2020 of Massachusetts General Laws:

Not requiring prior authorization:

1. In-network outpatient PCP or specialist visits.

2. In-network outpatient treatment with behavioral health providers.

3. In-network plasma exchange/apheresis.

4. Most first-line antibiotic treatments.

   Requiring prior authorization (through pharmacy):

5. IVIG therapy.

6. Rituxan.

   II. Non-covered services for PANS and PANDAS.

   A. Infusion therapies done outside of a medical setting (e.g., naturopathic or other alternative setting) are considered EXPERIMENTAL and INVESTIGATIONAL.

   B. Cunningham Genetic Panel is considered EXPERIMENTAL and INVESTIGATIONAL.

   C. Homeopathic, naturopathic, herbal, dietary or other supplements, Pulse Electromagnetic Frequency therapy, Advanced Bioregulation therapy, Craniosacral therapy, Hypnotherapy and Emotional Freedom Technique (EFT) Tapping therapy are all considered EXPERIMENTAL and INVESTIGATIONAL.

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Coding Guidance

There are no HCPCS codes specific to the treatment of PANS or PANDAS

ICD-10 Code
Description
D89.9 Disorder involving the immune mechanism, unspecified

References

PANS: Pediatric acute-onset Neuropsychiatric Syndrome. https://med.stanford.edu/pans.html.

An Act Promoting a Resilient Health Care System That Puts Patients First, Chapter 260, March 10, 2020 Session Law - Acts of 2020 Chapter 260 (malegislature.gov).
http://malegislature.gov/Bills/191/S2984.

“Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part II—Use of Immunomodulatory Therapies,” Journal of Child and Adolescent Psychopharmacology, Published Online: 1 Sep 2017. https://doi.org/10.1089/cap.2016.0148.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 12/2023 Moved to New Template. No changes. 1/2024 Added Line of Business Section 10/2024 Annual Review with no changes.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of

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public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government, or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.