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Description:
| NOTE: This policy has been combined with the policy on Pervasive Developmental Disorders / Autism Spectrum Disorders: Assessment, X-43.
Pervasive developmental disorders (PDD) include autistic disorder, Rhett’s disorder, childhood disintegrative disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified (NOS). These disorders are cognitive and neurobehavioral and are characterized by impairments in three core areas: social interactions, verbal and/or nonverbal communication, and restricted, repetitive patterns of behavior. Scientific evidence supporting specific treatment programs for pervasive developmental disorders is lacking. However, there is general agreement among experts that early intervention improves functioning and possibly IQ. Unfortunately, challenges to early identification of children with developmental disorders, including PDD, have not been overcome. Therefore, the following strategy/policy is recommended in order to increase rates of early diagnosis and treatment of PDD. |
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Policy:
| Identification of Developmental Concern
The detection of developmental disorders, including PDD, is an integral component of well-child care. Child health professionals are mandated to provide early identification of and intervention for children with developmental disabilities. This mandate is reaffirmed in Title V of the Social Security Act and the Individuals with Disabilities Education Improvement Act of 2004. Developmental concerns should be identified and addressed through developmental surveillance at each pediatric preventive care visit throughout the first five years of life. The five components of developmental surveillance are as follows: eliciting and attending to the parents’ concerns about their child’s development; documenting and maintaining a developmental history; making accurate observations of the child; identifying risk and protective factors; and maintaining an accurate record of the process and findings.
A standardized developmental screening tool must be administered at 9 months, 18 months, and 30 months of age OR at any time concerns regarding development are raised by the parents or others. Screening must also occur if developmental surveillance demonstrates risk. If screening results are concerning, then the child should be scheduled for diagnostic developmental and medical evaluations. The purpose for these evaluations is to identify the specific disorder/disorders and the underlying etiology of the disorder.
Diagnostic Evaluation of Pervasive Developmental Disorder
There are 3 aspects in the diagnostic evaluation of a child suspected of having PDD:
To assist with diagnosis, the clinician makes use of informant based measures, structured diagnostic interviews,
observational measures and symptom checklists.
Dimensional assessments focus on specific areas of
functioning such as IQ, language testing, adaptive
functioning, social interactions, and behavioral
problems. These evaluations may include performance-
based measures, semi structured interviews, or informant-
based measures.
- Individual Patient Evaluation
A complete diagnostic evaluation must include an
assessment of the parents’ chief complaint. Chief
complaints should be characterized simply and clearly
with an estimation of the frequency, intensity, and
impact of the behavior.
A complete evaluation of a child suspected of having a PDD
should always include use of PDD- specific diagnostic tools that incorporate measures of all of the following: intellectual functioning, language development, adaptive skills, and behavioral problems. Therefore, the evaluation is necessarily multidisciplinary, and includes at a minimum an experienced psychologist for IQ and other testing, and a speech pathologist for a language/ communication assessment. A variety of mental health professionals can administer the Vineland if trained, as well as the screening of audiology and tympanometry. Comprehensive hearing tests must be performed by an audiologist with experience in testing very young children.
The developmental diagnostic and medical evaluation also includes all of the following:
- The child’s developmental history, focusing on developmental milestones and delays.
- Family history; examples of important information include whether there are other family members with autism, mental retardation, fragile X syndrome, and tuberous sclerosis.
- Child’s medical history such as signs of deterioration, seizure activity, brain injury, head circumference.
- Conduct or secure the results of a recent physical exam.
- Lead screening for those children with mental retardation.
- Review of educational (school) system records.
- Other testing as indicated (e.g., neuropsychological, occupational therapy, physical therapy, family functioning, genetic, x-ray, laboratory, testing, electrophysiologic).
Treatment for Pervasive Developmental Disorders
- Detailed description of parent education and support services is delineated in the treatment plan.
- Coordination of care by a licensed/eligible provider/program.
- A multidisciplinary treatment plan is developed in cooperation with the family and is based on the results of the multidisciplinary assessment.
- Interventions are specific to the child’s identified and quantified disabling symptoms and are provided by trained, licensed/eligible professionals/programs with expertise in treating the targeted deficits.
- Goals and measures of progress for each intervention are specified with adjustments in approach that match persistent symptoms.
- Coordination of specific therapies with school (educational system) programs.
The Behavioral Health Policy Committee considers evaluation for and treatment of PDD as evidence-based and ACCEPED MEDICAL PRACTICE when all of the aforementioned components of identification, screening, evaluation, and treatment are included in the process. |
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Coverage:
| Prior authorization: No
However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.
Coverage is subject to the member’s contract benefits |
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| Coding: | CPT Codes 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809,
90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819,
90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90846, 90847,
90849, 90862, 90885, 90887, 90889, 90899
with Diagnoses 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90,
or 299.91
Additional CPT Codes: 99381-99394, 96110, 99210-99215, 96111, 99241-99245, 99080, 99354, 99354, 99355, 99358, 99359, |
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| Behavioral Health Policy Committee Review: | Developed April 10, 2002
Reviewed April 9, 2003
Revised May 12, 2004
Reviewed January 12, 2005
Reviewed January 11, 2006
Revised January 10, 2007
Reviewed February 14, 2007
Reviewed March 12, 2008
Approved for Inactivation March 11, 2009 (Policy combined into Pervasive Developmental Disorders / Autism Spectrum Disorders: Assessment) |
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| Behavioral Health Policy Subcommittee Review: | |
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| Cross Reference: | |
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