01/26/17. Replaces Effective Policy Dated: Autism Spectrum Disorders in Children: Assessment 01/19/16 and Evaluation Reference #: MP/A005 Page 1 of 4

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1 Reference #: MP/A005 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan (PCHP) PreferredOne Insurance Company (PIC) Individual PreferredOne Insurance Company (PIC) Large Group PreferredOne Insurance Company (PIC) Small Group Please refer to the member s benefit document for specific information. To the extent there is any inconsistency between this policy and the terms of the member s benefit plan or certificate of coverage, the terms of the member s benefit plan document will govern. Benefits must be available for health care services. Health care services must be ordered by a physician, physician assistant, or nurse practitioner. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. PURPOSE: The intent of this policy is to ensure that an autism spectrum disorder diagnosis is assigned only after a thorough evaluation has been conducted by appropriate professionals using proven effective assessment and evaluative methodology. GUIDELINES: Must have confirmed diagnosis from the DSM autism spectrum disorder as evidenced by both of the following: I and II I. Evaluation performed by an appropriate licensed provider one of the following: A-D A. Psychiatrist; or B. Licensed Clinical Psychologist; or C. Primary care physician with expertise in child development; or D. Neurologist. II. Evaluation included documentation of all of the following: A-C A. Review of developmental history and progress of development; and B. Symptoms of concern that interfere with functioning (such as, but not limited to, social, education and family functioning). C. An assessment of all of the following in more than one setting (such as, but not limited to, home and school): Use of imaginative play, stereotypic behaviors, narrow range of interests; and

2 Reference #: MP/A005 Page 2 of 4 2. Communication; and 3. Social interaction and relationships; and 4. Behaviors/responses to the environment; and 5. Functional impairment based on objective test scores and clinical observations of functioning. EXCLUSIONS: Any of the following: I or II I. Refer to member s benefit plan for specific exclusions. II. The following evaluation/assessment services are considered investigative (see Investigative List) A. Allergy testing B. Erythrocyte glutathione peroxidase studies C. Event-related brain potentials D. Intestinal permeability studies E. Magnetoencephalography/magnetic source imaging F. Neuroimaging studies such as CT, MRI, MRS, SPECT, and fmri G. Provocative chelation tests for mercury H. Stool analysis I. Tests for: celiac antibodies, immunologic or neurochemical abnormalities, micronutrients such as vitamin levels, metallathioneim protein assessment, mitochondrial disorders including lactate and pyruvate, thyroid function, and urinary peptides DEFINITIONS: Autism Spectrum Disorder: A range of complex neurodevelopmental disorders, characterized by persistent deficits in social communication and interaction across multiple contexts, restricted repetitive patterns of behavior, interests, or activities, symptoms that are present in the early developmental period, that cause clinically significant impairment in social, occupational, or other important areas of functioning, and are not better explained by intellectual disability or global developmental delay. DSM: The most current edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Health Disorders.

3 Reference #: MP/A005 Page 3 of 4 FOR INTERNAL USE ONLY COVERAGE: Prior Authorization: No Coverage is subject to the member s contract benefits. RELATED CRITERIA/POLICIES: Process Manual: UR015 Use of Medical Policy and Criteria Medical Criteria: MC/M020 Autism Spectrum Disorders: Non-Intensive Treatment Medical Criteria: MC/M024 Autism Spectrum Disorders: Early Intensive Behavioral and Developmental Therapy Medical Criteria: MC/N003 Occupational and Physical Therapy: Outpatient Setting Medical Criteria: MC/N004 Speech Therapy: Outpatient Setting Medical Policy: MP/C001 Court Ordered Mental Health Services. Medical Policy: MP/C009 Coverage Determination Guidelines Medical Policy: MP/I001 Investigative Services REFERENCES: 1. NIH National Institute of Neurological Disorders and Stroke (NINDS); NINDS Asperger Syndrome Information Page, Last Updated June 15, 2011, Accessed September 13, NINDS Autism Information Page, Last Updated June 15, 2011, Accessed September 13, Autism Fact Sheet, NINDS, Publication date September 2009 NIH Publication No , Accessed September 13, NINDS Pervasive Developmental Disorders Information Page, Last Updated June 15, 2011, Accessed September 13, NINDS Rett Syndrome Information Page, Last Updated June 15, Accessed September 13, National Guideline Clearinghouse (NGC). 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 from Accessed on September 16, Therapies for Children with Autism Spectrum Disorders. Comparative Effectiveness Review No. 26. (Prepared by hhsa i.) AHRQ Publication No. 11-EHC National Institute of Mental Health (NIMH). A Parent s Guide to Autism Spectrum Disorder Retrieved from 5. American Academy of Pediatrics. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 2012;129;1186; doi: /peds Myers SM, Plauche Johnson C. Management of children with autism spectrum disorders. Pediatrics 2007; 120; doi: /peds Weissman L, Bridgemohan C. Autism spectrum disorders in children and adolescents: Behavioral and educational interventions UpToDate. Retrieved from =1%7E8&provider=noProvider#H19 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition

4 Reference #: MP/A005 Page 4 of 4 DOCUMENT HISTORY: Created Date: 11/22/13 (previously part of MC/A020) Reviewed Date: 11/21/14, 11/20/16, 11/18/16 Revised Date:

5 PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PCHP LV (10/16)

6 PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PIC LV (10/16)