Attention-Deficit/Hyperactivity Disorder (ADHD .
Medical Coverage PolicyEffective Date . 1/15/2021Next Review Date. 1/15/2022Coverage Policy Number . 0231Attention-Deficit/Hyperactivity Disorder (ADHD):Assessment and TreatmentTable of ContentsRelated Coverage ResourcesOverview . 1Coverage Policy.1General Background .3Medicare Coverage Determinations .19Coding/Billing Information .19References .22AcupunctureBiofeedbackCognitive RehabilitationComplementary and Alternative MedicineGenetic CounselingGenetic Testing for Hereditary and MultifactorialConditionsIntensive Behavioral InterventionsNeuropsychological TestingSensory and Auditory Integration Therapy Facilitated CommunicationSpeech TherapyTranscranial Magnetic StimulationINSTRUCTIONS FOR USEThe following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines ofbusiness only provide utilization review services to clients and do not make coverage determinations. References to standard benefit planlanguage and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpretingcertain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document[Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] maydiffer significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plandocument may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefitplan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coveragemandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specificinstance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicablelaws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particularsituation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations fortreatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to supportmedical necessity and other coverage determinations.OverviewThis Coverage Policy addresses services for the assessment and treatment of attention-deficit hyperactivitydisorder.Coverage PolicyCoverage for behavioral services varies across plans. Refer to the customer’s benefit plan document forcoverage details. Services provided by a psychiatrist, psychologist or other behavioral healthprofessionals may be subject to the provisions of the applicable behavioral health benefit. Assessmentand treatment for comorbid behavioral health and/or medical diagnoses and associated symptomsand/or conditions may be covered under applicable medical and behavioral health benefit plans.Page 1 of 28Medical Coverage Policy: 0231
Coverage of medications related to the treatment of ADHD is subject to the pharmacy benefit of theapplicable benefit plan.When coverage is available, services for the treatment of ADHD are considered medically necessarywhen the criteria of the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM5) are met.Each of the following services is considered not medically necessary for the assessment and/ortreatment of ADHD: education and achievement testing, including Intelligence Quotient (IQ) testingeducational intervention (e.g., classroom environmental manipulation, academic skills training, andparental training)Each of the following procedures/services is considered experimental, investigational or unproven forthe assessment and/or treatment of ADHD:Assessment: actometercomputerized electroencephalogram (EEG) (e.g., brain mapping, neurometrics, or quantitativeelectroencephalography [QEEG], Neuropsychiatric EEG-Based Assessment Aid [NEBA] System)computerized tests of attention and vigilanceevent-related potentials (i.e., evoked potential studies)hair analysisneuroimaging (e.g., computerized tomography [CT], magnetic resonance imaging [MRI], positronemission tomography [PET] and single-photon emission computerized tomography [SPECT])Quotient ADHD Test/SystemTreatment: acupuncture/acupressureanti-candida albicans and antifungal medicationsanti-motion sickness medicationauditory integration therapybrain training/cognitive programs/gameschiropractic manipulationcognitive rehabilitationdietary treatmentsDore program/Dyslexia Dyspraxia Attention Treatment (DDAT)EEG biofeedback/neurofeedbackherbal remediesintensive behavioral intervention programs (e.g., early intensive behavior intervention [EIBI] intensivebehavior intervention [IBI], Lovaas therapy, applied behavior analysis [ABA])megavitamin therapymetronome trainingmovement therapyNeuro-Emotional Technique (NET)sensory integration therapytranscranial magnetic stimulation/cranial electrical stimulationvision therapyPage 2 of 28Medical Coverage Policy: 0231
General BackgroundAttention-deficit/hyperactivity disorder (ADHD) is a common disorder of childhood and adolescence that ischaracterized by symptoms of inattention and/or hyperactivity/impulsivity. In this disorder, the symptoms havepersisted for at least six months, to a degree that is maladaptive and inconsistent with developmental level. Thehyperactive-impulsive or inattention symptoms that cause impairment are present before age seven, althoughmany individuals are diagnosed after the symptoms have been present for a number of years. Some impairmentfrom the symptoms is present in two or more settings (e.g., at home and at school).The Diagnostic and Statistical Manual of Mental disorders, Fifth edition (DSM-5) notes that there are threesubtypes of ADHD (American Psychiatric Association [APA]), 2013):Diagnostic Criteria from Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)for:314.01 (F90.2) Attention-Deficit/Hyperactivity Disorder, combined type: If both Criterion A1 (inattention)and Criterion A2 (hyperactivity/impulsivity) are met for the past six months.314.00 (F90.0) Attention-Deficit/Hyperactivity Disorder, predominantly inattentive type: If Criterion A1(inattention) is met but Criterion A2 (hyperactivity/impulsivity) is not met for the past six months.314.01 (F90.1) Attention-Deficit/Hyperactivity Disorder, predominantly hyperactive-impulsive type: IfCriterion A2 (hyperactivity/impulsivity) 1(inattention) is met but Criterion A1 (inattention) is not met for the pastsix months.A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning ordevelopment as characterized by (1) or (2):1) Inattention: six (or more) of the followingsymptoms of inattention have persisted for at leastsix months to a degree that is inconsistent withdevelopmental level and that negatively impactsdirectly on social and academic/occupationalactivities:Note: The symptoms are not solely amanifestation of oppositional behavior, defiance,hostility, or failure to understand tasks orinstructions. For older adolescents and adults (age17 and older), at least five symptoms are required.2) Hyperactivity-impulsivity: six (or more) of thefollowing symptoms of hyperactivity-impulsivity havepersisted for at least six months to a degree that isinconsistent with developmental level and thatnegatively impacts directly on social andacademic/occupational activities:Note: the symptoms are not solely a manifestation ofoppositional behavior, defiance, hostility, or a failure tounderstand tasks or instructions. For older adolescentsand adults (age 17 and older), at least five symptomsare required.a) Often fails to give close attention to details ormakes careless mistakes in schoolwork, at work,or during other activities (e.g., overlooks or missesdetail, work is inaccurate).b) Often has difficulty sustaining attention in tasksor play activities (e.g., has difficulty remainingfocused during lectures, conversations, or lengthyreading).c) Often does not seem to listen when spoken todirectly (e.g., mind seems elsewhere, even in theabsence of any obvious distraction).d) Often does not follow through on instructionsand fails to finish school work, chores, or duties inthe workplace (e.g., starts tasks but quickly losesfocus and is easily sidetracked).e) Often has difficulty organizing tasks andactivities (e.g., difficulty managing sequentiala) Often fidgets with or taps hands or feet or squirms inseat.b) Often leaves seat when remaining seated isexpected (e.g., leaves his or her place in theclassroom, in the office or other workplace, or in othersituations that require remaining in place).c) Often runs about or climbs in situations in where it isinappropriate (Note: in adolescents or adults, may belimited to feeling restless).d) Often unable to play or engage in leisure activitiesquietly.e) Is often "on the go" acting as if "driven by a motor"(e.g., is unable to be or uncomfortable being still forextended time, as in restaurants, meetings; may beexperienced by others as being restless or difficult tokeep up with).f) Often talks excessively.Page 3 of 28Medical Coverage Policy: 0231
tasks; difficulty keeping materials and belongingsin order; messy, disorganized work; has poor timemanagement; fails to meet deadlines).f) Often avoids, dislikes, or is reluctant to engagein tasks that require sustained mental effort (e.g.,schoolwork or homework; for older adolescentsand adults, preparing reports, completing forms,reviewing lengthy papers).g) Often loses things necessary for tasks oractivities (e.g., school materials, pencils, books,tools, wallets, keys, paperwork, eyeglasses,mobile telephones).h) Is often easily distracted by extraneous stimuli(for older adolescents and adults, may includeunrelated thoughts).i) Is often forgetful in daily activities (e.g., doingchores, running errands, for older adolescents andadults, returning calls, paying bills, keepingappointments).g) Often blurts out an answer before a question hasbeen completed (e.g., completes people’s sentences’cannot wait for turn in conversation).h) Often has difficulty waiting his or her turn (e.g., whilewaiting in line).i) Often interrupts or intrudes on others (e.g., butts intoconversations, games, or activities; may start usingother people’s things without asking or receivingpermission; for adolescents and adults, may intrudeinto or take over what others are doing).B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home,school, or work; with friends or relatives; in other activities).D. There is clear evidence that the symptoms interfere with, or reduce the quality of social, academic, oroccupational functioning.E. The symptoms do not occur exclusively during the course of schizophrenia or other psychotic disorder andare not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociativedisorders, personality disorder, substance intoxication or withdrawal).It should be specified if the condition is in partial remission: when full criteria were previously met, fewer than thefull criteria have been met for the past six months, and the symptoms still result in impairment in social,academic or occupational functioning.The severity should be specified:Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present and symptoms resultsin no more than minor impairments in social or occupational functioning.Moderate: Symptoms or functional impairment between “mild” and “severe” are present.Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that areparticularly severe, are presents, or the symptoms results in marked impairment in social or occupationalfunctioning.The DSM-5 notes that the designation of “other specified” (DSM-5 code 314.01) (F90.8) applies to presentationin which symptoms characteristic of attention-deficit/hyperactivity disorder that cause clinically significant distressor impairment in social, occupational or other important areas of functioning predominate but do not meet the fullcriteria for attention-deficit/hyperactivity disorder or any of the disorders in the neurodevelopmental disordersdiagnostic class. The other specified attention-deficit/hyperactivity disorder category is used in situations n whichthe clinician chooses to communicate the specific reason that the presentation does not meet the criteria forattention-deficit/hyperactivity disorder or any specific neurodevelopmental disorder. This is done by recording“other specified attention-deficit/hyperactivity disorder” followed by the specific reason (e.g. “with insufficientinattention symptoms”).The DSM-5 notes that the designation of “not otherwise specified” (NOS) (DSM-5 code 314.01) (F90.9) appliesto presentations in which symptoms characteristic of attention-deficit/hyperactivity disorder that cause clinicallysignificant distress or impairment in social, occupational or other important areas of functioning predominate butPage 4 of 28Medical Coverage Policy: 0231
not meet the full criteria of attention-deficit hyperactivity disorder or any of the disorder in theneurodevelopmental disorders diagnostic class. This should be used in situations in which the clinician choosesnot to specify the reason that the criteria are not met for attention-deficit hyperactivity disorder or for a specificneurodevelopmental disorder, and includes presentations in which there is insufficient information to make amore specific diagnosis.AssessmentThe diagnosis is clinical, based on findings that are derived from the history, physical and patient/familyinterviews. There are no specific diagnostic tests for ADHD. The established diagnostic tools used in theassessment of ADHD include: parent/child interview (to rule out other psychiatric or environmental causes of symptoms)medical evaluation with a complete medical history and physical examination (to assess for co-existingconditions)electroencephalogram (EEG) or neurological consult when the presence of focal signs or clinical findingsis suggestive of a seizure disorder or a degenerative neurological conditionThe use of the DSM-5 criteria is a standard of care for practitioners of all types (e.g., primary care, subspecialty,psychiatry and non-physician mental health providers) to use in the assessment and diagnosis of ADHD (APA,2013). Diagnosis usually requires several steps, and clinicians will generally need to carry out the evaluation inmore than one visit, often two to three visits. The behaviors must adversely affect functioning in school or in asocial setting. Information obtained from the parent and school can assist the physician in assessing the effectsthat the symptoms are having on classroom performance, self-esteem, and family and social relationships.Other psychological and developmental disorders, including oppositional defiant disorder, conduct disorder,depression, anxiety disorder, and learning disabilities, frequently coexist in children who are evaluated for ADHD.Assessment and examination for such coexisting disorders are an integral part of the evaluation process forADHD patients. Evidence for most of these coexisting disorders may be readily detected by the primary careclinician. For example, a family history of anxiety disorders, coupled with a patient's history of frequent fears anddifficulties with separation from caregivers, may suggest the presence of anxiety disorder either as the primarydiagnosis or as a comorbid diagnosis to ADHD. Several screening tests are available that can detect areas ofconcern for many of the mental health disorders that coexist with ADHD. Although these scales have not beentested for use in primary care settings and are not diagnostic tests for either ADHD or associated mental healthconditions, some clinicians may use them to establish high risk for coexisting psychological conditions.Other coexisting medical conditions may be present and include speech delays, auditory and visual processingdisorders (American Academy of Pediatrics [AAP], 2011). Depending on the clinical findings, evaluation of thecoexisting conditions may be needed; including speech and language evaluations, occupational therapyevaluation, audiological evaluations, central auditory testing. In addition to ADHD there are other conditions thatmay affect the ability to understand auditory information. An individual with ADHD may be a poor listener andhave difficulty understanding or remembering verbal information; however, the actual neural processing ofauditory input in the central nervous system (CNS) is intact. Rather, it is the attention deficit that is impeding theirability to access or use the auditory information that is coming in. Central auditory processing disorder, orauditory processing disorder, refers to the efficiency and effectiveness by which the CNS utilizes auditoryinformation (American Speech-Language-Hearing Association [ASHA], 2005).According to the literature, several medical screening tests and laboratory measures have been used to evaluatechildren with suspected ADHD. These include neuroimaging (e.g., computerized tomography [CT], magneticresonance imaging [MRI]), EEG, and neurological screening exams, as well as other miscellaneous laboratoryassessments (Brown, et al., 2001). The association between elevated lead levels and impairments in cognitivefunctioning, including attention problems, has been consistently reported in the literature. Brown et al. (2001)reviewed six studies and found no statistically significant associations in three of them. One study reported apositive association between lead level and behavioral problems. Two studies examined children screened fordisruptive behavioral problems and found associations between elevated lead levels and behavioral problems.Since these studies did not assess ADHD, however, the extent to which their findings may apply to children withthis disorder is unknown (Brown, et al., 2001). The studies' findings suggest an association between elevatedPage 5 of 28Medical Coverage Policy: 0231
lead levels and a range of behavioral problems, including inattention, but do not support the routine use of leadscreening as a diagnostic indicator for ADHD. Only when clinical or environmental factors are present is themeasurement of blood lead levels appropriate.Neuropsychiatric EEG-Based Assessment Aid (NEBA) System (NEBA Health, Augusta, GA) is a device that isbased on electroencephalogram (EEG) technology. It records different kinds of electrical impulses (waves) givenoff by neurons (nerve cells) in the brain and the number of times (frequency) the impulses are given off eachsecond. The NEBA System is a 15- to 20-minute non-invasive test that calculates the ratio of two standard brainwave frequencies, known as theta and beta waves. It is theorized that the theta/beta ratio has been shown to behigher in children and adolescents with ADHD than in children without it.The NEBA system was recently reviewed by the FDA through the de novo classification process, a regulatorypathway for some low- to moderate-risk medical devices that are not substantially equivalent to
E. The symptoms do not occur exclusively during the course of schizophrenia or other psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorders, personality
White Paper: Profound Effects of Brain Balance Exercises and Interactive Metronome and on a Subset of Children with Attention Deficit Hyperactivity Disorder Introduction Attention-deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders of childhood, and it often persists into adulthood2. ADHD is characterized by a triad of symptoms: inattention,
children who have been diagnosed with Attention Deficit Disorder (ADD) and Attention Deficit Disorder with Hyperactivity (ADHD). To date they have helped 24 children and have confirmed clear patterns in their work. Patricia Meyer’s insights are also enhanced by other si
Attention Deficit Hyperactivity Disorder (ADHD) is a condition that makes it hard for children to pay attention or sit still. It is one of the most common childhood conditions. Symptoms of ADHD include inattention, hyperactivity and impulsivity. If left untreated, these behaviors can cause
Attention Deficit Hyperactivity Disorder begins in childhood. The majority of children show symptoms at age 7 and some as young as age 3. Approximately 3 to 7 percent of children have ADHD. Attention Deficit Hyperactivity
Alberta Education Cataloguing in Publication Data Alberta. Alberta Education. Focusing on success : teaching students with Attention Deficit/Hyperactivity Disorder, grades 1-12. ISBN -7785-5166- 1. Attention-deficit-disordered children - Education - Alberta. 2. Hyperactive children - Education - Alberta. 3.
Attention Deficit Hyperactivity Disorder (ADHD) is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. According to age and setting, the behaviours associated with ADHD are often described as ‘disruptive’ but it is important to remember the positives too.
The association between attention deficit/ hyperactivity disorder and internet addiction: a systematic review and meta-analysis Bing-qian Wang1, Nan-qi Yao2, Xiang Zhou3, Jian Liu4* and Zheng-tao Lv5* Abstract Background: This study aimed to analyze the association between Attention Deficit/H
F41.1 Generalized anxiety disorder F40.1 Social phobia F41.2 Mixed anxiety and depressive disorder F33 Recurrent depressive disorder F43.1 Post-traumatic stress disorder F60.31 Borderline personality disorder F43.2 Adjustment disorder F41.0 Panic disorder F90 Hyperkinetic (attention deficit) disorder F42 Obsessive-compulsive disorder
