When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
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.
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Hanley GP, Iwata BA, McCord BE. Functional analysis of problem behavior: A review. J Appl Behav Anal. 2003;36(2): 147-185.
Hanley GP, Jin CS, Vanselow NR, et al. Producing meaningful improvement in problem behavior of recipient with autism via synthesized analyses and treatments. J Appl Behav Anal. 2014;47(1):16-36.
Hayes, Inc. Hayes Genetic Test Evaluation (Synopsis). Single Nucleotide Polymorphism (SNP) Chromosomal Microarray Analysis for Intellectual Disability, Developmental Delay, and/or Multiple Congenital Anomalies. Lansdale, PA: Hayes, Inc.; August, 2011.
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Huerta M, Bishop SL, Duncan A, Hus V, et al. Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV piagnoses of Pervasive developmental disorders. Am J Psychiatry. 2012;169(10):1056-1064.
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Kalsner L, Twachtman-Bassett J, Tokarski K, et al. Genetic testing including targeted gene panel in a diverse clinical population of children with autism spectrum disorder: Findings and implications. Mol Genet Genomic Med. 2018;6(2):171-185.
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Kearney HM, South ST, Wolff DJ, et al. American College of Medical Genetics recommendations for the design and performance expectations for clinical genomic copy number microarrays intended for use in the postnatal setting for detection of constitutional abnormalities. Genet Med. 2011;13(7):676-679.
Kearney HM, Thorland EC, Brown KK, et al. American College of Medical Genetics standards and guidelines for interpretation and reporting of postnatal constitutional copy number variants. Genet Med. 2011;13(7):680-685.
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Moeschler JB, Shevell M. Comprehensive evaluation of the child with intellectual disability or global developmental delays. Pediatrics.2014;134(3):903-918.
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Myers SM, Johnson CP, American Academy of Pediatrics (AAP) Council on Children with Disabilities. Management of children with autism spectrum disorders. Pediatrics.2007;120(5):1162-1182. (Reaffirmed: 2014). Also available on the AAP Web site at: http://pediatrics.aappublications.org/cgi/reprint/120/5/1162. Accessed June 03, 2019.
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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
AF Speciality Physician
AH Clinical Psychologist
AJ Clinical Social Worker
HM Less than Bachelor Degree level
HN Bachelors Degree level
HO Masters Degree level
HP Doctoral Level
UN 2 patients serviced
UP 3 patients serviced
UQ 4 patients serviced
UR 5 patients serviced
US 6 or more patients serviced
Policy: 05.00.32j:Speech and Non-Speech Generating Devices
Policy: 05.00.44k:Repair and Replacement of Durable Medical Equipment (DME)
Policy: 07.00.02i:Intravenous Chelation Therapy
Policy: 07.00.03n:Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
Policy: 07.03.03g:Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
Policy: 07.03.08i:Neuropsychological Testing for Neurologically Based Conditions
Policy: 10.03.01l:Physical Medicine, Rehabilitation, and Habilitation Services
Policy: 10.06.01l:Speech Therapy
Policy: 12.00.03g:Complementary and Integrative Health Services
Policy: 06.02.35y:Genetic Testing (Independence Administrators)