Humana Autism Spectrum Disorders Diagnosis and Treatments - Medicare Advantage Form

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/Transmittals. Type Title ID Number Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories NCD Magnetic Resonance Imaging 220.2 Autism Spectrum Disorders Diagnosis and Treatment Page: 2 of 16 LCD LCA LCD LCA LCD LCA LCA LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA Magnetic Resonance Angiography (MRA) Psychiatric Partial Hospitalization Programs Psychiatry and Psychology Services Psychological Services Coverage under the Incident to Provision for Physicians and Non- Physicians Medical Policy Article Speech-Language Pathology Outpatient Psychiatry and Psychology Services Psychiatric Partial Hospitalization Programs Speech-Language Pathology MRI and CT Scans of the Head and Neck Magnetic Resonance Angiography LCD Psychiatric Codes LCD LCA LCD LCA LCD LCA Speech-Language Pathology (SLP) Services: Communication Disorders Magnetic Resonance Angiography (MRA) Psychiatric Diagnostic Evaluation and Psychotherapy Services L33633 A56747 L33626 A56850 L33632 A56937 A52825 L33580 A52866 L34353 A57065 L34196 A57053 L34046 A57040 L35175 A57215 L34865 A56805 L35101 L35070 A54111 L34372 A57779 L33252 A57520 L354520 J6 - National Government Services, Inc. (Part A/B MAC) JK - National Government Services, Inc. (Part A/B MAC IL, MN, WI CT, NY, ME, MA, NH, RI, VT J15 - CGS Administrators, LLC (Part A/B MAC) KY, OH JF - Noridian Healthcare Solutions, LLC JH - Novitas Solutions, Inc. (Part A/B MAC) JL - Novitas Solutions, Inc. (Part A/B MAC) AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AR, CO, NM, OK, TX, LA, MS DE, DC, MD, NJ, PA JN - First Coast Service Options, Inc. (Part A/B MAC) FL, PR, US VI Autism Spectrum Disorders Diagnosis and Treatment Page: 3 of 16 LCD LCA Psychological and Neuropsychological Tests A57780 Description Autism spectrum disorders (ASD) are a group of biologically based chronic neurodevelopmental disorders characterized by persistent deficits in social communication/interaction and restricted, repetitive patterns of behavior, interests and activities. The exact cause is unknown, but is believed to have many factors, including a strong genetic component. Signs and symptoms of ASD generally appear prior to three years of age and include difficulties with language, deficient social skills and restricted or repetitive body movements and behaviors. There is no cure for ASD. However, there is a consensus that treatment must be individualized depending upon the specific strengths, weaknesses and needs of the child and family. Early diagnosis and early intensive treatment have the potential to affect outcome, particularly with respect to behavior, functional skills and communication. There is increasing evidence that intervention is more effective when initiated as early as possible. Diagnosis and treatment of ASD may involve a variety of tools. Developmental screening, usually performed during a routine well child exam, identifies atypical (unusual) behaviors such as social, interactive and communicative behaviors that are delayed, abnormal or absent. Once identified, a comprehensive multidisciplinary assessment is recommended in order to make an accurate and appropriate diagnosis. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: Autism Spectrum Disorders (ASD) Diagnosis and Treatment The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Autism Spectrum Disorders Diagnosis and Treatment Page: 4 of 16 Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage