What Services and Treatments Can Be Covered?

Generally, whether a treatment gets covered by health insurance is based on whether there are multiple trials in the medical literature which show that it is an effective treatment for a specific condition, combined with judicious medical opinion.   This is a growing field of health care called evidence based medicine.

The CA Department of Managed Health Care (DMHC) issued a policy, Improving Plan Performance for Autistic Spectrum Disorders, which basically requires CA health plans to pay for autism evaluations and provide speech, occupational, and physical therapy to people with autism.   This document can be useful to submit when a state regulated plan has denied your client any of the above mentioned therapies.

Useful Codes

Speech Therapy, assessment (92506), individual (92507) and group (92508) are usually covered.

Social skills therapy is often conducted by speech therapists in small pragmatic language groups and can be coded as group speech therapy (92508).

Occupational Therapy, assessments (97003) and for fine and gross motor delays (97110, 97112, 97140, 97530) are usually covered.  Some plans will cover occupational therapy for sensory integration dysfunction, but this can be controversial.   Remember that codes for occupational therapy sessions are in 15 minute intervals, a one hour session will require 4 units.  Some clients report higher rates of reimbursement for a combination of codes rather than 4 units of the same code.

Psychological therapy, including behavioral modification (90808), individual (90806) and group  (90853) psychotherapy.  Group social skills therapy, when conducted by a psychologist or licensed mental health provider, can be coded as group psychotherapy (90853).

Neuropsychological or psychological evaluations and assessments, especially when there is a question of diagnosis, can be covered by insurance companies (96116, 96118).  You may need prior authorization if the anticipated hours exceed the amount generally covered for other conditions.

Medications for treatment of autism and related co-morbid conditions are usually covered.

Family therapy related to autism, both with (90847) and without (90846) the patient present is generally covered.

Visits with developmental pediatricians and other physician specialists are generally covered (99214, 99215).  If you are in a PPO, visits with DAN doctors are generally covered.

See the TACANOW website for more information on specific CPT codes which families have used successfully to get insurance coverage.

Applied Behavioral Analaysis (ABA)

Some health plans are starting to provide ABA, or applied behavioral analaysis, generally when directed or supervised by licensed health professionals or Board Certified Behavioral Analaysts(BCBA). Families must fight very hard for these benefits.  Many large employers are starting to recognize the need for ABA therapy and are offering to provide it to employees with family members who need it.   A few health plans which offer services to self-insured companies are offering packages which include ABA.

Codes which have been used successfully for ABA include the following:  90806, 90808 (individual psychotherapy for 50-60 minutes, and 75-80 minutes, respectively); 97532 (15 minute, development of cognitive skills); 98960 – 1 on 1 education/self management with a non-physician provider, 30 minutes.

What is generally not covered?

DAN treatments are  frequently not covered, as there currently aren't an adequate number of controlled trials in the peer-reviewed medical literature which show efficacy.  (Some clients have reported limited success using alternative diagnostic codes, such as enzyme treatment for enzyme deficiencies yielding partial payment for tests and treatments in some PPOs.)  DAN doctor visits are sometimes reimbursed as out-of-network providers with some PPOs.

Therapies for learning disorders or treatments that the health plans can claim are educational or custodial in nature are generally not covered.

Other alternative type therapies are generally not covered.

Any type of therapy which lacks an evidence base is generally not covered.

How AHIP Can Help

AHIP provides free initial advice to providers of autism treatments to assist them in helping families receive insurance benefits.   Powerpoint presentations are available on request.   Consulting and collaborative arrangements are available to other non-profit organizations.