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 autistic individuals 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.
Comprehensive programs that offer ST and/or OT and/or PT as therapy for autistic individuals 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
Speech/language therapy for the treatment of autism is considered investigational. (Except when Tennessee State Mandate applies. See Applicable Tennessee State Mandate Requirements below.)
Occupational therapy for the treatment of autism is considered investigational. (Except when Tennessee State Mandate applies. See Applicable Tennessee State Mandate Requirements below.)
Physical therapy for the treatment of autism is considered investigational. (Except when Tennessee State Mandate applies. See Applicable Tennessee State Mandate Requirements below.)
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:
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(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. |
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(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. |
ADDITIONAL INFORMATION
Speech therapy and/or occupational therapy and/or physical therapy does not meet the following technology evaluation criteria:
The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
The technology must improve the net health outcome.
The technology must be as beneficial as any established alternatives.
The improvement must be attainable outside the investigational settings.
SOURCES
American Academy of Neurology. (2007). Practice parameter: screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Retrieved February 26, 2007 from http://www.neurology.org/cgi/reprint/55/4/468.pdf.
American Academy of Pediatrics. (2001). Policy statement: The pediatrician's role in the diagnosis and management of autistic spectrum disorder in children (RE060018). Pediatrics, 107 (5), 1221-1226.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2003). Occupational therapy (8.03.03). Retrieved February 16, 2007 from BlueWeb.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2003). Physical therapy (8.03.02). Retrieved February 16, 2007 from BlueWeb.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2003). Speech therapy (8.03.04). Retrieved February 16, 2007 from BlueWeb.
Canadian Paediatric Society. (2004, April). Position statement: Early intervention for children with autism. Retrieved May 26, 2005 from http://www.cps.ca/english/statements/PP/pp04-02.htm.
Code of Federal Regulations. Title 34, Volume 2. Section 300.7. (2002, July). Child with a disability. Retrieved July 24, 2003 from http://frwebgate6.access.gpo.gov/cgi-bin/waisgate.cgi?WAISdocID=06976398603+3+0+0&WAISaction=retrieve.
Code of Federal Regulations. Title 45, Volume 4. Section 1308.5. (2002, July). Eligibility criteria: Autism. Retrieved July 24, 2003 from http://frwebgate6.access.gpo.gov/cgi-bin/waisgate.cgi?WAISdocID=06976398603+1+0+0&WAISaction=retrieve.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2367. Autism spectrum disorders. Retrieved February 23, 2007 from http://198.187.128.12/tennessee/lpext.dll?f=templates&fn=fs-main.htm&2.0.
Tennessee Code: Title 49 Education: Chapter 10 Special Education: Part 1 General provisions: 49-10-102. Definitions. Retrieved March 22, 2005 from http://198.187.128.12/tennessee/lpext.dll?f=templates&fn=fs-main.htm&2.0.
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EFFECTIVE DATE |
4/12/2007 |
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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.