BlueCross BlueShield of Tennessee Medical Policy Manual

Speech / Language Therapy, Occupational Therapy and Physical Therapy for Autism Spectrum Disorder

Does not apply to BlueCare.

DESCRIPTION

Speech therapy (ST) is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis and rehabilitation. ST has been proposed as a treatment for individuals with autism spectrum disorder since this disorder is associated with severe language deficits, such as bizarre speech patterns, echolalia, or mutism.

Occupational therapy (OT) is a medically prescribed treatment concerned with improving or restoring functions that have been impaired by illness, injury or disability through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual. Occupational therapy provides training in the activities of daily living (ADL) and improves neuromusculoskeletal functions. Occupational therapy may also include the design, fabrication/use of orthoses, and guidance in the selection/use of adapted equipment.

Physical therapy (PT) is a medically prescribed treatment concerned with improving or restoring physical function following disease, injury, or loss of body part. Physical therapy uses therapeutic exercise and other interventions to improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and to reduce pain. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiologic principles.

Programs that may include speech and/or language therapy, occupational therapy and/or physical therapy as part of their services for individuals with autism spectrum disorder include, but are not limited to, the TEACCH program, the Denver Model, the LEAP program, Greenspan's Floor-Time Program and Sensory Integration Therapy.

POLICY

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

The Tennessee state law quoted below applies to individual policies, fully insured accounts, and self-funded accounts that are not governed by ERISA (i.e. governmental plans and church plans). Please keep in mind that it can be very difficult to determine if such a Plan is a governmental plan, (for example some utilities are governmental plans), or a church plan (for example some hospital plans are church plans.) This mandate applies to such accounts that are delivered, issued for delivery, amended or renewed on or after January 1, 2007. This mandate does not apply to self-funded accounts that are governed by ERISA unless an ERISA governed self-funded account's plan language, Explanation of Coverage (EOC), or Summary Plan Description provides coverage for these particular disorders. An ERISA governed self-funded plan's language will govern application of this policy to a plan. In addition, other federal laws will preempt this provision. In particular, the Federal Employees Program is governed by federal law and contains a provision that preempts claims and benefits similar to ERISA. The provisions of this mandate concern autism spectrum disorders and are applicable to individuals of less than twelve (12) years of age.

Tennessee Code Annotated, Title 56, Chapter 7, Part 23, was amended by adding the following languages as a new section to be appropriately designated:

(a)

As used in this section, "autism spectrum disorders" means neurological disorders, usually appearing in the first three (3) years of a person's life that affect normal brain functions and are typically manifested by impairments in communication and social interaction, as well as restrictive, repetitive, and stereotyped behaviors.

(b)

A contract or policy of an insurer that provides benefits for neurological disorders, whether under an individual or group health insurance policy providing coverage on an expense-incurred basis, an individual or group service contract issued by a health maintenance organization, a self-insured group arrangement to the extent not preempted by federal law or a managed health care delivery entity of any type or description shall provide benefits and coverage for treatment of autism spectrum disorders that are at least as comprehensive as those provided for other neurological disorders. These benefits and coverage for treatment shall be provided to any person less than twelve (12) years of age.

IMPORTANT REMINDERS

This medical policy does not apply to BlueCare.

SOURCES

Agency for Healthcare Research and Quality. U. S. Department of Health and Human Services. (2014, August). Effective Health Care Program. Comparative Effectiveness Review, Number 137. Therapies for children with autism spectrum disorder: behavioral interventions update. Retrieved April 21, 2016 from http://effectivehealthcare.ahrq.gov.

American Academy of Child and Adolescent Psychiatry AACAP) Committee on Quality Issues (CQI). (1999, reaffirmed 2014) Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Retrieved November 8, 2016 from http://www.guideline.gov. (NGC#010489).

American Academy of Neurology and Child Neurology Society (2000, reaffirmed 2014). Practice parameters: screening and diagnosis of Autism. Neurology, 55 (4), 468-479.

American Academy of Pediatrics (2012) Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Retrieved November 8,, 2016 from http://pediatrics.aappublications.org.

American Occupational Therapy Association. (2011). Occupational therapy practice guideline for children and adolescents with challenges in sensory processing and sensory integration. Retrieved December 23, 2015 from http://www.guideline.gov (NGC#008580).

Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et. al., (2010, January) Randomized, controlled trial of an intervention for toddlers with autism: the early start denver model. Pediatrics. Vol. 125, No. 1. (Level 2 evidence)

National Institute for Health and Care Excellence (2013, August) Autism spectrum disorder in under 19s: support and management. Retrieved November 8, 2016 from: www.nice.org.uk.  

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2367. Autism spectrum disorders. Retrieved November 8, 2016 from: http://www.lexisnexis.com.

U. S. Department of Health and Human Services. National Institute of Health. National Institute of Mental Health. (2008) Autism spectrum disorders; pervasive developmental disorders. Retrieved December 23, 2015 from: http://www.nimh.nih.gov. 

U. S. Department of Health and Human Services. National Institute of Health. National Institute of Mental Health. (2011) A parent’s guide to autism spectrum disorder. Retrieved December 23, 2015 from: nimhinfo@nih.gov.

U.S. Preventive Services Task Force. (2015, August) Screening for speech and language delay and disorders in children aged 5 years or younger. Retrieved November 8, 2016 from: http://www.guideline.gov. (NGC#010746).

U.S. Preventive Services Task Force. (2016, February) Screening for autism spectrum disorder in young children. Retrieved November 8, 2016 from: http://www.guideline.gov. (NGC#010905).

ORIGINAL EFFECTIVE DATE:  5/1/2002

MOST RECENT REVIEW DATE:  12/8/2016

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.