Medical Policy Bulletin

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Title:

Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)

Policy #:

07.03.03c

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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the medical necessity criteria for the medical evaluation and management of attention-deficit hyperactivity disorder (ADHD).

For information on policies related to this topic, refer to the Cross References Table in this policy.

Description:

Attention-deficit hyperactivity disorder (ADHD), also known as attention-deficit disorder (ADD), is one of the most common psychiatric disorders of childhood and adolescence. Signs and symptoms of ADHD may appear over the course of several months, frequently with the symptoms of impulsiveness and hyperactivity or inattention. It affects boys more often than girls, with symptoms usually present before the age of 7. While there is no specific test to confirm a diagnosis of ADHD, the diagnosis is applied to children and adults who display certain characteristic behaviors over a period of time. The most common behaviors fall into three types: Inattention (more common in females): It may be difficult for the individual to stay focused or to pay attention to detail. The individual is easily distracted and has difficulty learning something new or completing a task. Hyperactivity (more common in males): The individual is unable to sit still, appears to be always in motion, and may talk incessantly. Children may squirm in their seats, wiggle their feet, or touch everything. Adults and teens might feel restless, try to do several tasks at the same time, or bounce from one activity to another. Impulsivity: The individual has difficulty curbing immediate reactions and acts without thinking. In addition, symptoms of inattention and hyperactivity are manifested equally. CHILDREN Children with ADHD have functional impairments when interacting with peers, at school, and at home. School problems may include: Lower than expected or erratic grades Poor organization and study skills Gaps in learning Difficulty with test taking Failure to complete assignments and/or turn in homework. Behavior problems at school often lead to continuous friction among peers, teachers, and parents. This pattern of behavior often leads to suspension, placement in special classes, or expulsion. Research shows that ADHD tends to run in families, suggesting that there is a considerable genetic component to the etiology of ADHD. Siblings of children with ADHD have a two to three times higher risk of having ADHD when contrasted with the general pediatric population. Up to 80 percent of children diagnosed with ADHD continue to have symptoms of ADHD into adolescence and up to 65 percent into adulthood. Some literature suggests that children with ADHD are more likely to experiment with drugs and may develop a significant substance abuse problem. Forming a therapeutic alliance between the parents, the child, and the school to allow specific treatment interventions is the most crucial aspect of the treatment plan for a therapist and/or physician. Treatment plans need to be individualized according to the strengths identified during an evaluation and the pattern of target symptoms. Psychological interventions such as behavior modification alone are less effective than medication. Most controlled studies showed minimal benefit when behavior modification was added to pharmacotherapy. Parent training consists of teaching parents to give clear instructions, give positive reinforcement, and reprimand effectively. For parents and other family members, education is essential in the treatment of ADHD. Parents need to understand their child's developmental needs and develop practical strategies to meet educational and social goals. Family therapy might be appropriate to address family dysfunction related to the raising and managing of the child with ADHD or for primary parental or marital pathology resulting from living with a child with ADHD. ADOLESCENTS Adolescents with ADHD show a different clinical picture. These children tend to be restless instead of hyperactive. Adolescents diagnosed with ADHD tend to have low self-esteems, poor peer relations, and diminished school performances. Children who start on medication at an earlier age may or may not require a change in medication at puberty. Pharmacotherapy may be prescribed for newly diagnosed adolescents. ADULTS ADHD in adults tends to be missed. Most often adults seek evaluation and treatment after their child is diagnosed with ADHD. Some of the symptoms/comorbidities observed in adults include: Agitated depression Borderline or antisocial personality disorder Dissociative disorders Hypomania Alcohol and/or drug abuse Cognitive brain syndromes Education about ADHD is very important in the treatment plan. The same medications used for children are used in adults. Family therapy can be helpful in addressing the chaotic relationships that often result from ADHD symptoms. DIAGNOSTIC TOOLS Neuropsychological testing (which tests the functional integrity of the brain) may be helpful in evaluating suspected neurological comorbidities in an individual with suspected ADHD; however, there is no evidence basis for the use of neuropsychological testing in the evaluation of ADHD where such comorbidities are not suspected. Psychological testing should not be used for educational purposes, only for diagnostic reasons. Psychoeducational testing to evaluate for learning disabilities often associated with ADHD should be performed by the child's school under the federal mandate: Individuals with Disabilities Education Act (IDEA). Electroencephalograms (EEGs) are only indicated in the presence of clinical suggestions of a comorbid condition such as a seizure disorder or a degenerative condition. PHARMACOTHERAPY The determination to medicate is based on an ADHD diagnosis and sufficiently severe symptoms to cause functional impairment at school, at home, and with peers. A stimulant (eg, methylphenidate) is the first medication of choice. Stimulants are fast-acting, easily titrated, and have mostly mild and easily reversed side effects. However, medication should not be a substitute for appropriate educational curricula. Children and adolescents should not be responsible for administering their own medication, due to the fact that they are impulsive, disorganized, and usually dislike taking medication. PSYCHOTHERAPIES Psychotherapies may be used to address secondary problems and disorders. Behavior modification is a psychological intervention that relies on rewarding positive behavior to increase the frequency of such behavior. Such positive rewards can be as simple as praising a child on the little things accomplished and complimenting a child about a job well done several times throughout the day. NONTRADITIONAL TREATMENTS The American Academy of Child and Adolescent Psychiatry (AACAP) identifies the following as examples of nontraditional treatments: Elimination diets (eg, Feingold diet) Anti-motion sickness medicine Nutritional supplements (eg, megadoses of vitamins) Antifungal therapy Biofeedback Sensory integration Optometric vision training Chiropractic manipulation However, the AACAP also warns that these treatments are based on uncontrolled studies, therefore, lacking efficacy and scientific support. ELIMINATION DIET One of the most common dietary interventions is the adherence to the Feingold diet. This diet focuses on the theory that children are sensitive to dietary salicylates, artificially added colors, flavors, and preservatives; therefore, eliminating these offenders from the diet could potentially improve a child's learning disability and improve behavioral problems. NUTRITIONAL SUPPLEMENTATION Nutritional supplementation takes the opposite position of dietary elimination. This theory is based on the assumption that something is missing from the diet and what is determined to be missing should be added in optimum amounts. This theory includes such things as megadoses of vitamin(s), zinc, iron, amino acids, and herbal supplements. ANTIMOTION SICKNESS MEDICATION The theory behind antimotion sickness medicine is that a relationship exists between ADHD and the inner ear system. The inner ear system plays a key role in balance and coordination. This treatment includes a combination of medications such as meclizine and/or cyclizine sometimes mixed with stimulants. ANTIFUNGAL THERAPY The belief behind this treatment is that toxins produced by overgrown yeast weakens the immune system and makes the body receptive to ADHD and other psychiatric disorders. Proponents recommend the use of antifungal agents such as nystatin while restricting sugar intake. At the present time, there is no data to support the use of antifungal medications in the treatment of ADHD. ELECTROENCEPHALOGRAM (EEG) BIOFEEDBACK Electroencephalogram (EEG) biofeedback (also known as neurofeedback) is based on the findings that some individuals with ADHD show lower levels of arousal in the frontal brain area. The goal of biofeedback is to teach these individuals to tolerate increased arousal levels. This improves attention and reduces impulsive behavior and hyperactivity. Although there have been encouraging studies in the use of neurofeedback in the treatment of ADHD, there are no definitive studies to support neurofeedback in the treatment of ADHD at this time. INTERACTIVE METRONOME An interactive metronome is a computerized version of a simple metronome. The goal of this therapy is to have the individual attempt to match the rhythmic beat with hand or foot tapping. This improves motor planning and timing skills. SENSORY INTEGRATION Sensory integration (SI) dysfunction is a condition where the brain is overloaded by too many sensory messages and is not able to respond. There are some pediatricians who postulate that SI dysfunction and ADHD are associated. SI is based on a theory that this dysfunction can be bypassed by organizing information and presenting it through multiple sensory modalities. There have been some controlled and uncontrolled studies conducted using various strategies; however, the state of the empirical evidence regarding these interventions is uneven, ranging from no data to well-controlled trials. CHIROPRACTIC There are several theories about chiropractic treatment for ADHD based on the belief that spinal problems are the cause of health problems. Advocates believe that spinal adjustment can effectively treat ADHD and learning disabilities. The theory behind this approach is that learning disabilities are caused by the misalignment of the sphenoid bone (at the base of the skull) and the temporal bones. This misalignment is purported to create unequal pressure on different areas of the brain causing brain dysfunction. There are no definitive studies to support chiropractic use in the treatment of ADHD. OPTOMETRIC VISION TRAINING (ORTHOPTIC/PLEOPTIC) Advocates of this treatment (eg, eye exercises, perceptual training) believe that visual problems such as faulty eye movement, sensitivity to certain light frequencies, and focus problems create reading disorders. However, there are no definitive studies available to support this claim. REHABILITATIVE THERAPIES (OCCUPATIONAL, PHYSICAL, AND SPEECH) Rehabilitative therapies should not be considered routine treatment for ADHD. Occupational, physical, and/or speech therapy are only appropriate when there is evidence of a physical or neurological condition where rehabilitative therapy(ies) may be useful in treating such a condition. There is no available published literature that validates these therapies in the treatment of an individual with ADHD.

Policy

EVALUATION All of the following are considered medically necessary and, therefore, covered for the medical evaluation of attention-deficit hyperactivity disorder (ADHD): A complete physical examination within the last 12 months (including blood tests such as lead levels and quantitative plasma amino acid assays to detect phenylketonuria) A comprehensive medical history Interviews with the parents and child to establish problem patterns of behavior and parent-child and child-peer conflicts MANAGEMENT Medical management of ADHD through physician office visits are covered under the member's medical benefit. Pharmacological therapy in the management of ADHD may be covered under the prescription plan when the member has a pharmacy benefit. NOT MEDICALLY NECESSARY Nontraditional treatments for ADHD such as, but not limited to, the following are considered not medically necessary and, therefore, not covered: Elimination diets (eg, Feingold diet) Nutritional supplements (eg, megadoses of vitamins) Antifungal therapy Electroencephalogram (EEG) biofeedback Antimotion sickness medication Physical, occupational, and/or speech therapy are considered not medically necessary and, therefore, not covered in the treatment of ADHD, unless the individual has a neurological or physical deficit that requires such therapy. EXPERIMENTAL/INVESTIGATIONAL Nontraditional treatments for ADHD such as, but not limited to, the following, lack validation and scientific support, and are considered experimental/investigational and, therefore, not covered: Sensory integration therapy Optometric vision training (orthoptic/pleoptic) Interactive metronome training (a computerized version of keeping the beat, which provides auditory feedback) Chiropractic

Guidelines

The federal Individuals with Disabilities Education Act (IDEA) mandates educational testing for learning disabilities; therefore, treating health care professionals might recommend that the school district conduct psychoeducational testing if learning disabilities are suspected. For psychotherapies used in the treatment of attention-deficit hyperactivity disorder (ADHD), please refer to the mental health vendor. MEDICARE This policy is consistent with Medicare's coverage determination. BENEFIT APPLICATION Subject to the terms and conditions of the applicable benefit contract, the medical evaluation for ADHD are covered under the medical benefits of the Company's products when medical necessity criteria in the medical policy are met.

References

Highmark Medicare Services. V-17F: Psychiatric Interviews and Evaluation Procedures. [Highmark Medicare Services Web site]. Original: 08/11/97. (Revised 09/30/05). Available at: http://www.highmarkmedicareservices.com/policy/partb/v1/v17f.html. Accessed June 19, 2007. Highmark Medicare Services. V-41G: Psychiatric Therapeutic Procedures. [Highmark Medicare Services Web site]. Original: 08/11/97. (Revised 09/30/05). Available at: http://www.highmarkmedicareservices.com/policy/partb/v1/v41g.html. Accessed June 19, 2007. National Institute of Mental Health (NIMH). Attention Deficit Hyperactivity Disorder. [NIMH Web site]. 03/06/2007. Available at: http://www.nimh.nih.gov/healthinformation/adhdmenu.cfm. Accessed June 19, 2007. National Resource Center on AD/HD. About AD/HD. Causes and Pathophysiology. [CHADD Web site]. Available at: http://www.help4adhd.org/en/about/causes. Accessed June 19, 2007. Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med.2005;352(2):165-173. Available at: http://www.nejm.org. Accessed February 15, 2005. Smucker WD, Hedayat M. Evaluation and treatment of ADHD. Am Fam Physician.2001;64(5):817-829.

Coding Table

Inclusion of a code in this table does not imply reimbursement coverage. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	N/A
ICD Procedure	N/A
ICD Diagnosis	314.00: Attention deficit disorder of childhood without mention of hyperactivity 314.01: Attention deficit disorder of childhood with hyperactivity 314.1: Hyperkinesis of childhood with developmental delay 314.2: Hyperkinetic conduct disorder of childhood 314.8: Other specified manifestations of hyperkinetic syndrome of childhood 314.9: Unspecified hyperkinetic syndrome of childhood V58.69: Encounter for long-term (current) use of other medications V58.83: Encounter for therapeutic drug monitoring
HCPCS Level II	N/A
Revenue Codes	N/A

Cross References

Version Effective Date: 09/11/2007