Humana Autism Spectrum Disorders Diagnosis and Treatment Form
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.26 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 Autism Spectrum Disorders Diagnosis and TreatmentEffective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 2 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing 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.29
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.8
For information regarding proposed evaluation methods for ASD not addressed in this policy, please see the following Medical Coverage Policies:
- Allergy testing
- Artificial intelligence (AI)
- Multianalyte assays with algorithmic analyses (MAAAs)
- Physical therapy (PT)
- Occupational therapy (OT)
For information regarding proposed treatments for ASD not addressed in this policy, please see the following Medical Coverage Policies:
- Applied behavior analysis (ABA)
- Cognitive rehabilitation
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Complementary or alternative medicine (CAM) practices
- Fecal microbiota transplantation (FMT)
- Hyperbaric oxygen therapy
- Physical Therapy
- Sensory integration therapy (SIT)
- Speech generating devices
- Speech Therapy
- Vagus nerve stimulation
Coverage Determination
Any services for ASD that are considered primarily educational or training in nature are generally NOT covered under most Humana benefit Plans.
Any state mandates for ASD diagnosis and treatment take precedence over this medical coverage policy.
ASD screening and surveillance may be available through state or local early childhood identification programs funded by the US Department of Education.
Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.
Evaluation and Diagnosis
Humana members may be eligible under the Plan for ASD evaluation and diagnosis when developmental delays or persistent deficits in social communication and social interaction across multiple contexts have been identified and when the evaluation is performed by the appropriate certified/licensed health care professional which may include one or more of the following:
- Board certified behavioral analyst; OR
- Developmental pediatrician; OR
- Neurologist; OR
- Occupational therapist; OR
- Physical therapist; OR
- Primary care provider; OR
- Psychiatrist; OR
- Psychologist; OR
- Speech-language pathologist and audiologist
AND may include one or more of the following methods:
- ASD specific developmental screening
- Cognitive and adaptive behaviors evaluations
- Lead testing
- Medical and neurological evaluations
- Metabolic testing in children with any of the signs or symptoms of metabolic disease8,25 including:
- Cyclic vomiting, recurrent vomiting and dehydration; OR
- Developmental regression; OR
- Dysmorphic or coarse features; OR
- Early seizures; OR
- Hearing impairment; OR
- Hypotonia; OR
- Inadequate or questionable newborn screen; OR
- Intellectual disability or intellectual disability cannot be ruled out; OR
- Lethargy; OR
- Unusual odor; OR
- Vision impairment
- Neuropsychological, behavioral and academic assessments
- Sleep-deprived electroencephalogram (EEG) is indicated only for the following conditions:
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- Clinical seizures; OR
- Suspicion of subclinical seizures; OR
- History of regression (clinically significant loss of communicative and social function) at any age, but especially in toddlers and preschoolers
Treatment
Humana members may be eligible under the Plan for ASD treatment using behavior modification (may be subject to applicable behavioral health benefit)
Coverage Evaluation and Diagnosis
Coverage Limitations
Evaluation and Diagnosis
Humana members may NOT be eligible under the Plan for ASD evaluation and diagnosis by any other methods not listed above including, but not limited to:
- Celiac antibody testing; OR
- Erythrocyte glutathione peroxidase studies; OR
- Event-related brain potentials (auditory evoked response screening); OR
- Hair analysis; OR
- Immunologic or neurochemical abnormality testing (eg, immunoglobulin, gamma aminobutyric acid [GABA]); OR
- Intestinal permeability studies; OR
- Magnetoencephalography; OR
- Micronutrients (trace elements, trace minerals or vitamin) level testing; OR
- Mitochondrial toxicity (including lactate and pyruvate) testing; OR
- Neuroimaging studies (eg, computed tomography [CT] scan, functional magnetic resonance imaging [fMRI], MRI, positron emission tomography [PET] scan); OR
- Quantitative EEG (QEEG); OR
- Stool analysis; OR
- Thyroid function testing; OR
- Urinary peptide testing
These are considered experimental/investigational, as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.
Treatment
Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.
Any state mandates for ASD diagnosis and treatment take precedence over this medical coverage policy.
Any services for ASD that are considered primarily educational or training in nature are generally NOT covered under most Humana benefit Plans.
Humana members may NOT be eligible under the plan for ASD treatment by any other methods not listed above including, but not limited to, the following:
- Cord blood/stem cell infusion or transplantation; OR
- Dietary therapy (eg, elimination diets); OR
- Facilitated communication; OR
- Holding therapy; OR
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- Immune globulin infusion (for information regarding coverage determination/ limitations, please refer to IVIG [immune globulin] Pharmacy Coverage Policy); OR
- Nutritional supplements (eg, megavitamins, high-dose pyridoxine and magnesium, dimethylglycine and glutathione) (may be excluded by certificate); OR
- Photobiomodulation via wearable light emitting diode (LED), EEG sensors and feedback loop via AI platform (Cognilum); OR
- Secretin infusion; OR
- Sensory-based therapies, such as:
- Auditory integration training (AIT); OR
- Sound therapy; OR
- Vestibular stimulation; OR
- Vision therapy (orthoptics and vision training may be excluded by certificate); OR
- Weighted blankets or vests; OR
- Therapies involving education* or training, such as:
- Computer or video-based programs (eg, GemIInii Systems); OR
- Developmental, Individual Difference, Relationship-Based (DIR/Floortime; Stanley Greenspan) Model; OR
- Relationship Developmental Intervention (RDI); OR
Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 8 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
These are considered experimental/investigational, as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language. *Interventions that are primarily educational or training in nature are generally excluded by certificate. Please refer to the member’s certificate language regarding coverage of treatments that may be considered primarily educational or training.
Additional information about autism spectrum disorder may be found from the following websites:
Background
- American Academy of Child and Adolescent Psychiatrists
- American Academy of Pediatrics
- National Clearinghouse on Autism Evidence and Practice
- National Institute of Mental Health
- National Institute of Neurological Disorders and Stroke
- National Library of Medicine
Medical Alternatives
Physician consultation is advised to make an informed decision based on an individual’s health needs.
Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.
Provider Claims Codes
| CPT® Code(s) | Description P | Comments |
|---|---|---|
| 38240 | Hematopoietic progenitor cell (HPC); allogeneic transplantation donor | Not Covered if used to report any treatment outlined in Coverage Limitations section |
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| 38241 | Hematopoietic progenitor cell (HPC); autologous transplantation | Not Covered if used to report any treatment outlined in Coverage Limitations section |
| 70450 | Computed tomography, head or brain; without contrast material | Not Covered if used to report ASD diagnosis and treatment |
| 70460 | Computed tomography, head or brain; with contrast material(s) | Not Covered if used to report ASD diagnosis and evaluation |
| 70470 | Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections | Not Covered if used to report ASD diagnosis and evaluation |
| 70496 | Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing | Not Covered if used to report ASD diagnosis and evaluation |
| Magnetic resonance angiography, head; without contrast material(s) | Not Covered if used to report ASD diagnosis and evaluation | |
| 70544 | Magnetic resonance angiography, head; with contrast material(s) | Not Covered if used to report ASD diagnosis and evaluation |
| 70545 70546 | Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences | Not Covered if used to report ASD diagnosis and evaluation |
| 70551 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material | Not Covered if used to report ASD diagnosis and evaluation |
| 70552 | Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) | Not Covered if used to report ASD diagnosis and evaluation |
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 70555 | Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing | Not Covered if used to report ASD diagnosis and evaluation |
|---|---|---|
| 76390 | Magnetic resonance spectroscopy | Not Covered if used to report ASD diagnosis and evaluation |
| 78600 | Brain imaging, less than 4 static views; | Not Covered if used to report ASD diagnosis and evaluation |
| 78601 | Brain imaging, less than 4 static views; with vascular flow | Not Covered if used to report ASD diagnosis and evaluation |
| 78605 | Brain imaging, minimum 4 static views; | Not Covered if used to report ASD diagnosis and evaluation |
| 78606 | Brain imaging, minimum 4 static views; with vascular flow | Not Covered if used to report ASD diagnosis and evaluation |
| 78608 | Brain imaging, positron emission tomography (PET); metabolic evaluation | Not Covered if used to report ASD diagnosis and evaluation |
| 78609 | Brain imaging, positron emission tomography (PET); perfusion evaluation | Not Covered if used to report ASD diagnosis and evaluation |
| 82136 | Amino acids, 2 to 5 amino acids, quantitative, each specimen | Not Covered if used to report ASD diagnosis and evaluation |
| 82139 | Amino acids, 6 or more amino acids, quantitative, each specimen | Not Covered if used to report ASD diagnosis and evaluation |
| 82180 | Ascorbic acid (Vitamin C), blood | Not Covered if used to report ASD diagnosis and evaluation |
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation
| 82306 | Vitamin D; 25 hydroxy, includes fraction(s), if performed | Not Covered if used to report ASD diagnosis and evaluation |
| 82310 | Calcium; total | Not Covered if used to report ASD diagnosis and evaluation |
| 82607 | Cyanocobalamin (Vitamin B-12); | Not Covered if used to report ASD diagnosis and evaluation |
| 82608 | Cyanocobalamin (Vitamin B-12); unsaturated binding capacity | Not Covered if used to report ASD diagnosis and evaluation |
| 82652 | Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed | Not Covered if used to report ASD diagnosis and evaluation |
| 82725 | Fatty acids, nonesterified | Not Covered if used to report ASD diagnosis and evaluation |
| 82726 | Very long chain fatty acids | Not Covered if used to report ASD diagnosis and evaluation |
| 82746 | Folic acid; serum | Not Covered if used to report ASD diagnosis and evaluation |
| 82747 | Folic acid; RBC | Not Covered if used to report ASD diagnosis and evaluation |
| 82784 | Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each | Not Covered if used to report ASD diagnosis and evaluation |
| 82785 | Gammaglobulin (immunoglobulin); IgE | Not Covered if used to report ASD diagnosis and evaluation |
Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 12 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 83015 | Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); qualitative, any number of analytes | Not Covered if used to report ASD diagnosis and evaluation |
| 83018 | Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each, not elsewhere specified | Not Covered if used to report ASD diagnosis and evaluation |
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method | Not Covered if used to report ASD diagnosis and evaluation |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified | Not Covered if used to report ASD diagnosis and evaluation |
| 83540 | Iron | Not Covered if used to report ASD diagnosis and evaluation |
| 83655 | Lead | Not Covered if used to |
| 83735 | Magnesium | report ASD diagnosis and evaluation Not Covered if used to |
| 84100 | Phosphorus inorganic (phosphate); | report ASD diagnosis and evaluation Not Covered if used to |
| 84105 84207 | Phosphorus inorganic (phosphate); urine Pyridoxal phosphate (Vitamin B-6) | report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and |
| 84252 | Riboflavin (Vitamin B-2) | evaluation Not Covered if used to report ASD diagnosis and |
Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Not Covered if used to report ASD diagnosis and evaluation Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 13 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 84425 | Thiamine (Vitamin B-1) | Not Covered if used to report ASD diagnosis and evaluation |
|---|---|---|
| 84443 | Thyroid stimulating hormone (TSH) | Not Covered if used to report ASD diagnosis and evaluation |
| 84446 | Tocopherol alpha (Vitamin E) | Not Covered if used to report ASD diagnosis and evaluation |
| 84479 | Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) | Not Covered if used to report ASD diagnosis and evaluation |
| 84590 | Vitamin A | Not Covered if used to report ASD diagnosis and evaluation |
| 84591 | Vitamin, not otherwise specified | Not Covered if used to report ASD diagnosis and evaluation |
| 84597 | Vitamin K | Not Covered if used to report ASD diagnosis and evaluation |
| 84630 | Zinc | Not Covered if used to report ASD diagnosis and evaluation |
| 84999 | Unlisted chemistry procedure | Not Covered if used to report ASD diagnosis and evaluation |
| 86255 | Fluorescent noninfectious agent antibody; screen, each antibody | Not Covered if used to report ASD diagnosis and evaluation |
| 86256 | Fluorescent noninfectious agent antibody; titer, each antibody | Not Covered if used to report ASD diagnosis and |
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| this is the | current version before utilizing. | |
|---|---|---|
| 88346 | Immunofluorescence, per specimen; initial single antibody stain procedure | Not Covered if used to report ASD diagnosis and |
| evaluation | ||
|---|---|---|
| 88350 | Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) | Not Covered if used to report ASD diagnosis and evaluation |
| 90791 | Psychiatric diagnostic evaluation | Coverage is subject to the provision of the applicable behavioral health benefit |
| 90792 | Psychiatric diagnostic evaluation with medical services | Coverage is subject to the provision of the applicable behavioral health benefit |
| 90832 | Psychotherapy, 30 minutes with patient | Coverage is subject to the provision of the applicable behavioral health benefit |
| 90833 | Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) | Coverage is subject to the provision of the applicable behavioral health benefit |
| 90834 | Psychotherapy, 45 minutes with patient | Coverage is subject to the provision of the applicable behavioral health benefit |
| 90836 | Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) | Coverage is subject to the provision of the applicable behavioral health benefit |
| 90837 | Psychotherapy, 60 minutes with patient | Coverage is subject to the provision of the applicable behavioral health benefit |
90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Coverage is subject to the provision of the applicable behavioral health benefit Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 15 of 29
| this is the | current version before utilizing. | applicable behavioral |
|---|---|---|
| Preparation of report of patient's psychiatric status, history, | health benefit Any coverage is subject to | |
| 92065 | Orthoptic and/or pleoptic training, with continuing medical direction and evaluation Orthoptic training; under supervision of a physician or other qualified health care professional | Not Covered New Code Effective |
| 92066 | 01/01/2023 | |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual | |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals | Not Covered |
| 92605 | Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour | Not Covered |
| 92606 | Therapeutic service(s) for the use of non-speech-generating device, including programming and modification | Not Covered |
| 92607 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; |
| 92608 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) | Not Covered if used to report ASD treatment |
| 92609 | Therapeutic services for the use of speech-generating device, including programming and modification | Not Covered if used to report ASD treatment |
92650 Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis Not Covered if used to report ASD treatment Not Covered if used to report ASD diagnosis and evaluation
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 92651 | Auditory evoked potentials; for hearing status determination, re broadband stimuli, with interpretation and report | Not Covered if used to report ASD diagnosis and evaluation |
| 92652 | Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report | Not Covered if used to report ASD diagnosis and evaluation |
| 92653 | Auditory evoked potentials; neurodiagnostic, with interpretation and report | Not Covered if used to report ASD diagnosis and evaluation |
| 95004 | Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests | Not Covered if used to report ASD diagnosis and evaluation |
| 95024 | Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests | Not Covered if used to report ASD diagnosis and evaluation |
| 95027 | Tests with unspecified allergenic extracts, delayed type reaction, including test interpretation and report, specify number of tests | Not Covered if used to report ASD diagnosis and evaluation |
| 95028 | Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests | Not Covered if used to report ASD diagnosis and evaluation |
| 95044 | Patch or application test(s) (specify number of tests) | Not Covered if used to report ASD diagnosis and evaluation |
| 95052 | Photo patch test(s) (specify number of tests) | Not Covered if used to report ASD diagnosis and evaluation |
| 95056 | Photo tests | Not Covered |
| 95060 | Ophthalmic mucous membrane tests | Not Covered |
| 95065 | Direct nasal mucous membrane test | Not Covered |
Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 17 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 95700 | Electroencephalogram (EEG) continuous recording, with video when performed, setup, patient education, and takedown when performed, administered in person by EEG technologist, minimum of 8 channels |
| 95705 | Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; unmonitored |
| 95706 | Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; with intermittent monitoring and maintenance |
| 95707 | Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance |
| 95708 | Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored |
| 95709 | Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance |
| 95710 | Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous, real-time monitoring and maintenance |
| 95711 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored |
| 95712 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with intermittent monitoring and maintenance |
| 95713 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance |
Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; unmonitored Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with intermittent monitoring and maintenance Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; unmonitored
95714 Autism Spectrum Disorders Diagnosis and TreatmentEffective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 18 of 29
| 95715 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with intermittent monitoring and maintenance |
| 95716 | Electroencephalogram with video (VEEG), review of data, technical description by EEG technologist, each increment of 12-26 hours; with continuous, real-time monitoring and maintenance |
| 95717 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; without video |
| 95718 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) |
| 95719 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; without video |
| 95720 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; with video (VEEG) |
| 95721 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, without video |
Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 19 of 29
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When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 95722 | or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG) | |
| 95723 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG recording, without video | |
| 95724 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG) | |
| 95725 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG recording, without video | |
| 95726 | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG recording, with video (VEEG) | |
| 95812 | Electroencephalogram (EEG) extended monitoring; 41-60 minutes | Not Covered if used to report any test outlined in Coverage Limitations section |
| 95813 | Electroencephalogram (EEG) extended monitoring; 61-119 minutes | Not Covered if used to report any test outlined in Coverage limitations section |
| 95816 | Electroencephalogram (EEG); including recording awake and drowsy |
Autism Spectrum Disorders Diagnosis and TreatmentEffective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 20 of 29 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 95819 | Electroencephalogram (EEG); including recording awake and asleep | |
| 95822 | Electroencephalogram (EEG); recording in coma or sleep only | |
| 95957 | Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) | Not Covered if used to | report any test outlined in Coverage Limitations section |
| 95961 | Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of attendance by a physician or other qualified health care professional | Not Covered if used to | report ASD diagnosis and evaluation |
| 95962 | Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; at each additional hour of attendance by a physician or other es : . . ws qualified health care professional (List separately in addition to code for primary procedure) | Not Covered if used to . . report ASD diagnosis and . |
| 95965 | Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization) | Not Covered if used to report ASD diagnosis and evaluation |
| 95966 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (eg, sensory, motor, language, or visual cortex localization) | Not Covered if used to report ASD diagnosis and evaluation |
| 95967 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (eg, sensory, motor, language, or visual cortex localization) (List separately in addition to code for primary procedure) | Not Covered if used to report ASD diagnosis and evaluation |
| 96020 | Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results | Not Covered if used to report ASD diagnosis and evaluation |
Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 21 of 29
| 96110 | Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument |
| 96112 | Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour |
| 96113 | Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure) |
| 96116 | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour |
| 96121 | Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure) |
Autism Spectrum Disorders Diagnosis and Treatment Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 22 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 96130 | Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
| 96131 | each additional hour (List separately in addition to code for primary procedure) |
| 96132 | Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour |
| 96133 | each additional hour (List separately in addition to code for primary procedure) |
| 96136 | Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes |
| 96137 | each additional 30 minutes (List separately in addition to code for primary procedure) |
Autism Spectrum Disorders Diagnosis and TreatmentEffective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 23 of 29
| 96138 | Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes | |
| 96139 | each additional 30 minutes (List separately in addition to code for primary procedure) | |
| 96146 | with single automated, standardized instrument via electronic platform, with automated result only | |
| 96902 | Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality | Not Covered |
| 97039 | Unlisted modality (specify type and time if constant attendance) | Not Covered if used to report ASD treatment |
| 97112 | neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities | Not Covered if used to report ASD treatment |
| 97151 | behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan | |
| 97152 | behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes |
Autism Spectrum Disorders Diagnosis and TreatmentEffective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 24 of 29
| this is the | current version before utilizing. | |
|---|---|---|
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes | |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes | |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes | |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes | |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes | |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes | |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes | Not Covered |
CPT® Category III Code(s)
Description
Comments
No code(s) identified
HCPCS Code(s)
Description
Comments
E1902
Communication board, nonelectronic augmentative or alternative communication device
Not Covered
Autism Spectrum Disorders Diagnosis and TreatmentEffective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 25 of 29
Humana's documents are updated regularly online.
When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| J2850 | Injection, secretin, synthetic, human, 1 mc; ) ’ ed ’ ’ 8 | Not Covered if used to report ASD treatment |
|---|---|---|
| J3415 | oa ca. Injection, pyridoxine HCI, 100 mg | Not Covered if used to report ASD treatment |
| J3475 | Injection, magnesium sulfate, per 500 mg | Not Covered if used to report ASD treatment |
| P2031 | Hair analysis (excluding arsenic) | Not Covered |
| $8035 | Magnetic source imaging | Not Covered |
| $8040 | Topographic brain mapping | Not Covered |
| $8948 | Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes | Not Covered if used to report ASD treatment |
References
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- Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- American Academy of Child and Adolescent Psychiatry (AACAP). Policy Statement (ARCHIVED). Facilitated communication. https://www.aacap.org. Published June 2008. Accessed January 27, 2023.
- American Academy of Child and Adolescent Psychiatry (AACAP). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. https://www.aacap.org. Published February 2014. Accessed January 20, 2023.
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- American Academy of Pediatrics (AAP). Clinical Report. Identification, evaluation and management of children with autism spectrum disorders. https://www.aap.org. Published January 2020. Accessed January 20, 2023.
- American Academy of Pediatrics (AAP). Dietary interventions for autism spectrum disorder: a meta-analysis. https://www.aap.org. Published November 2019. Accessed February 3, 2023.
References
- Interventions targeting sensory challenges in autism spectrum disorder: a systematic review. https://www.aap.org. Published June 2017. Accessed February 3, 2023.
- American Academy of Pediatrics (AAP). Policy Statement. Cord blood banking for potential future transplantations. https://www.aap.org. Published November 2017. Accessed February 3, 2023.
- American Academy of Pediatrics (AAP). Policy Statement. Prevention of childhood lead toxicity. https://www.aap.org. Published July 2016. Accessed February 3, 2023.
- Autism Spectrum Disorders Diagnosis and Treatment
Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 27 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. - American College of Radiology (ACR). ACR-ASNR-SPR Practice parameter for the performance of functional magnetic resonance imaging (fMRI) of the brain. https://www.acr.org. Published 2007. Updated 2022. Accessed February 1, 2023.
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- Hayes, Inc. Emerging Technology Report. Cognilum transcranial photobiomodulation (tPBM) for autism spectrum disorder. https://evidence.hayesinc.com. Published February 10, 2022. Accessed January 31, 2023.
- Hayes, Inc. Medical Technology Directory (ARCHIVED). Positron emission tomography (PET) for autism spectrum disorders. https://evidence.hayesinc.com. Published September 1, 2010. Updated August 5, 2014. Accessed January 31, 2023.
- Hayes, Inc. Medical Technology Directory (ARCHIVED). Sensory-based treatments for autistic spectrum disorders. https://evidence.hayesinc.com. Published May 9, 2011. Updated April 9, 2015. Accessed January 31, 2023.
- Autism Spectrum Disorders Diagnosis and Treatment
Effective Date: 03/01/2023 Revision Date: 03/01/2023 Review Date: 03/01/2023 Policy Number: HUM-0303-036 Page: 28 of 29
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. - Hayes, Inc. Medical Technology Directory (ARCHIVED). Social skills training for autistic spectrum disorders. https://evidence.hayesinc.com. Published October 20, 2011. Updated October 7, 2015. Accessed January 31, 2023.
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