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Coverage criteria policies

Intensive behavioral therapy for autism - Wisconsin

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

These criteria apply to group health benefit plans subject to Wisconsin statutes Section 632.895 (12m).

For members in the above mentioned products whose coverage includes this mandated benefit, this treatment requires prior authorization by the Behavioral Health Department. These services are not covered for other products.

Coverage

The health plan covers evidence based intensive-level and non-intensive level treatment of autism spectrum disorders as described below under indications that are covered.

Intensive behavioral therapy treatment programs that are not evidence based or otherwise do not comply with these criteria are not covered. Examples are listed below under indications that are not covered.

Indications that are covered

Intensive-level services
Intensive−level services means evidence−based behavioral therapy that is designed to help an individual with autism spectrum disorder overcome the cognitive, social, and behavioral deficits associated with that disorder.

Intensive−level services means evidence−based behavioral therapies that are directly based on, and related to, an insured’s therapeutic goals and skills as prescribed by a physician familiar with the insured. Intensive-level service may include evidence-based speech therapy and occupational therapy provided by a qualified therapist when such therapy is based on, or related to, an insured’s therapeutic goals and skills, and is concomitant with evidence-based behavioral therapy.

  1. Coverage is provided for evidence-based behavioral intensive-level therapy for a member with a verified diagnosis of autism spectrum disorder, the majority of which shall be provided to the member when the parent or legal guardian is present and engaged and all of the prescribed therapy is consistent with all of the following requirements:
    1. Based upon a treatment plan developed by a qualified provider that includes at least 20 hours per week over a six month period of time of evidence-based behavioral intensive therapy, treatment, and services with specific cognitive, social, communicative, self-care, or behavioral goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorders. Treatment plans shall require that the member be present and engaged in the intervention. Minimum coverage need not be met if it is determined by a supervising professional in consultation with the insured’s physician that less treatment is medically appropriate.
    2. Implemented by qualified providers, qualified supervising providers, qualified professionals, qualified therapists or qualified paraprofessionals.
    3. Provided in an environment most conducive to achieving the goals of the member’s treatment plan.
    4. Included training and consultation, participation in team meetings and active involvement of the member’s family and treatment team for implementation of the therapeutic goals developed by the team.
    5. Commenced on or after a member is two years of age and completed on or before the member is nine years of age. 2
    6. The member is directly observed by the qualified provider at least once every two months. 2
  2. The health plan will cover up to 48 cumulative months of intensive-level services. The health plan may credit against the required four years of intensive-level services any previous intensive-level services the member received regardless of payer. Documentation, including medical records and treatment plans, may be required to verify any evidence-based behavioral therapy the member received for autism spectrum disorders that was provided to the member prior to the member attaining nine years of age. The health plan may consider any evidence-based behavioral therapy that was provided to the member for an average of 20 or more hours per week over a continuous six-month period to be intensive-level services.
  3. Travel time for qualified providers, supervising providers, professionals, therapists or paraprofessionals will not be used when calculating the number of hours of care provided per week and will not be separately reimbursed.
  4. Qualified providers must assess and document the member’s progress throughout the course of treatment. The health plan may request and review the member’s treatment plan and the summary of progress on a periodic basis.

Transition to non-intensive-level services

Insurers and self-insured plans shall provide notice to the insured or the insured’s authorized representative regarding change in an insured’s level of treatment. The notice shall indicate the reason for transition that may include any of the following:

  1. The insured has received forty-eight cumulative months of intensive-level services.
  2. The insured no longer requires intensive-level services as supported by documentation from a qualified supervising provider, qualified intensive-level provider, or a qualified intensive-level professional.
  3. The insured no longer receives evidence-based behavioral therapy for at least 20 hours per week over a six month period of time. .

Non-intensive-level services
Non-intensive-level services means evidence−based therapy that occurs after the completion of treatment with intensive − level services and that is designed to sustain and maximize gains made during treatment with intensive−level services or, for an individual who has not and will not receive intensive−level services, evidence−based therapy that will improve the individual’s condition.

  1. Coverage will be provided for a member with a verified diagnosis of autism spectrum disorder for non-intensive-level services that are evidence-based and that are provided to a member by a qualified provider, professional, therapist or paraprofessional in either of following conditions:
    1. After the completion of intensive-level services and designed to sustain and maximize gains made during intensive-level services treatment.
    2. To a member who has not and will not receive intensive-level services but for whom non-intensive-level services will improve the member’s condition.
  2. The health plan will provide coverage for evidence-based therapy that:
    1. is based upon a treatment plan developed by a qualified provider, supervising provider, professional or therapist that includes specific therapy goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorders. Treatment plans shall require that the member be present and engaged in the intervention;
    2. is implemented by qualified providers, qualified supervising providers, qualified professionals, qualified therapists or qualified paraprofessionals;
    3. is provided in an environment most conducive to achieving the goals of the member’s treatment plan;
    4. includes training and consultation, participation in team meetings and active involvement of the member’s family in order to implement the therapeutic goals developed by the team; and
    5. provides supervision of providers, professionals, therapists and paraprofessionals by qualified supervising providers on the treatment team.
  3. The health plan will provide coverage for non-intensive-level services that may include direct or consultative services when provided by qualified providers, qualified supervising providers, qualified professionals, qualified paraprofessionals, or qualified therapists.
  4. Qualified providers must assess and document the member’s progress throughout the course of treatment. The health plan may request and review the member’s treatment plan and the summary of progress on a periodic basis.
  5. Travel time for qualified providers, supervising providers, professionals, therapists or paraprofessionals will not be used when calculating the number of hours of care provided per week and will not be separately reimbursed.

Locations for Services

  1. Insurers and self-insured health plans shall cover treatments, therapies and services to an insured diagnosed with autism spectrum disorders in locations including the provider’s office, clinic or in a setting conducive to the acquisition of the target skill. Treatments may be provided in schools when they are related to the goals of the treatment plan and do not duplicate services provided by a school.
  2. Insurers and self-insured health plans are not required to cover therapy, treatment or services when provided to an insured who is residing in a residential treatment center, inpatient treatment or day treatment facility.
  3. Insurers and self-insured health plans are not required to cover the cost for the facility or location or for the use of a facility or location when treatment, services or evidence based therapy are provided outside an insured’s home.

Indications that are not covered

  1. Acupuncture2
  2. Animal-based therapy including hippotherapy2
  3. Auditory integration training2
  4. Chelation therapy2
  5. Child care fees2
  6. Cranial sacral therapy2
  7. Custodial or respite care2
  8. Hyperbaric oxygen therapy2
  9. Special diets or supplements2

Definitions

Autism spectrum disorder” means any of the following6

  1. Autism disorder
  2. Asperger’s syndrome
  3. Pervasive developmental disorder not otherwise specified6

Evidence-based means therapy that is based upon medical and scientific evidence, and is determined to be an efficacious treatment or strategy and is prescribed to improve the insured’s condition or to achieve social, cognitive, communicative, self-care or behavioral goals that are clearly defined within the insured’s treatment plan..2

Our Medical Director determines which therapies are evidence based, in accordance with established processes and principles.

Efficacious treatment or efficacious strategy means treatment or strategies designed to address cognitive, social or behavioral conditions associated with autism spectrum disorders; to sustain and maximize gains made during intensive-level services; or to improve an individual with autism spectrum disorder’s condition.2

Therapy means services, treatments and strategies prescribed by a treating physician and provided by a qualified provider to improve the member’s condition or to achieve social, cognitive, communicative, self-care or behavioral goals that are clearly defined within the member’s treatment plan.2

Provider means a state-licensed psychiatrist, psychologist, or a social worker certified or licensed to practice psychotherapy.2

Qualified paraprofessional means an individual working under the active supervision of a qualified supervising provider and who complies with all of the following2

  1. Attains at least 18 years of age.
  2. Obtains a high school diploma
  3. Completes and passes a criminal background check.
  4. Obtains at least 20 hours of training that includes subjects related to autism, evidence-based treatment methods, communication, teaching techniques, problem behavior issues, ethics, special topics, natural environment, and first aid.
  5. Obtains at least 10 hours of training in the use of behavioral evidence-based therapy including the direct application of training techniques with an individual who has autism spectrum disorder present.
  6. Receives regular, scheduled oversight by a qualified provider in implementing the treatment plan for the member. 2

Qualified intensive-level provider means an individual identified in s. 632.895 (12m) (b) 1. to 4., Stats., acting within the scope of a currently valid state-issued license for psychiatry, psychology or behavior analyst, or a social worker acting within the scope of a currently valid state-issued certificate or license to practice psychotherapy, who provides evidence-based behavioral therapy in accordance with this section and s. 632.895 (12m) (a) 3., Stats., and who has completed at least 2080 hours of training, education and experience which includes all of the following: Fifteen hundred hours supervised training involving direct 1:1 work with individuals with autism spectrum disorders using evidence-based, efficacious therapy models.

Supervised experience with all of the following:

  1. Working with families as the primary provider and ensuring treatment compliance.
  2. Treating individuals with autism spectrum disorders who function at a variety of cognitive levels and exhibit a variety of skill deficits and strengths.
  3. Treating individuals with autism spectrum disorders with a variety of behavioral challenges.
  4. Treating individuals with autism spectrum disorders who have shown improvement to the average range in cognitive functioning, language ability, adaptive and social interaction skills.
  5. Designing and implementing progressive treatment programs for individuals with autism spectrum disorders.
  6. Academic coursework from a regionally accredited higher education institution with demonstrated coursework in the application of evidence-based therapy models consistent with best practice and research on effectiveness for individuals with autism spectrum disorders

Qualified professional means an individual identified in s. 632.895 (12m) (b) 5.,Stats., acting under the supervision of an outpatient mental health clinic certified under s.51.038, Stats., acting within the scope of a currently valid state-issued license and who provides evidence-based therapy

Qualified provider means an individual identified in s. 632.895 (12m) (b) 1. to 4.,Stats., respectively, acting within the scope of a currently valid state-issued license for psychiatry, psychology or behavior analyst, or a social worker acting within the scope of a currently valid state-issued certificate or license to practice psychotherapy and who provides evidence-based therapy in accordance with this section.

Qualified supervising provider means an individual who is a qualified intensive-level provider and who has completed at least 4160 hours of experience as a supervisor of less experienced providers, professionals and paraprofessionals.

Qualified therapist means an individual identified in s. 632.895 (12m) (b) 6. or 7.,Stats., who is either a speech-language pathologist or occupational therapist acting within the scope of a currently valid state-issued license and who provides evidence-based therapy in accordance with this section, sub. (4) (e).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

ICD-10-CM Codes

    Codes

    Description

    F84.0

    Autistic spectrum disorder

    F84.5

    Asperger’s syndrome

    F84.8

    Other pervasive developmental disorders

    F84.9

    Pervasive developmental disorder, unspecified

Procedure Codes:

    Codes

    Description

    T1025

    Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem

    T1025-TF

    Non-Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem (Intermediate level )

    T1026

    Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, medical and psychosocial impairments, per hour

    T1027

    Family training and counseling for child development, per 15 minutes

Skills Training & Development

    Codes

    Description

    H2014

    Skills training and development, per 15 minutes

Modifiers

    Modifiers

    Description

    GO

    Services delivered under an outpatient occupational therapy plan of care

    TF

    Intermediate level of care

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. State of Wisconsin Statutes - ss. 600.01, 628.34 (12), 632.895 (12m) Stats – Analysis prepared by the office of the Commissioner of Insurance (OCI) https://www.openminds.com/wp-content/uploads/indres/100110iddwiautisminsrule.pdf
  2. Wis. Stat. Chapter 632.895 (12m)(a) -http://www.legis.state.wi.us/statutes/Stat0632.pdf
  3. Wisconsin State Legislature – Ins 3.36 coverage of autism spectrum disorders.

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Policy activity

  • 01/06/2010 - Date of origin
  • 01/01/2017 - Effective date
Review date
  • 01/2018
Revision date
  • 01/01/2015

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