Attention Deficit-Hyperactivity Disorder

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Attention Deficit-Hyperactivity DisorderPolicy Number: PG0338Last Review: 01/08/2019ADVANTAGE ELITE HMOINDIVIDUAL MARKETPLACE PROMEDICA MEDICAREPLAN PPOGUIDELINESThis policy does not certify benefits or authorization of benefits, which is designated by each individualpolicyholder contract. Paramount applies coding edits to all medical claims through coding logic softwareto evaluate the accuracy and adherence to accepted national standards. This guideline is solely forexplaining correct procedure reporting and does not imply coverage and reimbursement.SCOPEX ProfessionalFacilityDESCRIPTIONAttention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood.Approximately eight to ten percent of school age children are diagnosed with ADHD, and males are predominantlymore affected than females. It is common for a person with ADHD to be affected by comorbidities, which are otherconditions that exist simultaneously with and independent of ADHD. Examples include, but may not be limited to,oppositional defiant disorder, conduct disorder, depression, anxiety disorder and learning disabilities. AlthoughADHD is usually diagnosed in childhood, it often lasts into adulthood.The behavior of children with ADHD can typically be classified into three different subtypes: Predominantly inattentive Predominantly hyperactive-impulsive Combined typeADHD is characterized by a pattern of behavior, present in multiple settings (e.g., school and home), that can resultin performance issues in social, educational or work settings. There is no single test to diagnose ADHD. Typically,a diagnosis is made by a comprehensive exam that assesses the onset and course of symptoms consistent withADHD. A functional assessment, if conducted, evaluates both the severity of impairment and the pervasiveness ofsymptoms occurring in different environments.The parameters for diagnosing ADHD are found in the Fifth Edition of the Diagnostic and Statistical Manual ofMental Disorders (DSM-5), published by the American Psychiatric Association (APA). The DSM-5 includes a set ofdiagnostic criteria that indicate the symptoms that must be present to establish the diagnosis of ADHD.There are several types of specialists qualified to diagnose and treat ADHD. Examples include, but may not belimited to, child psychiatrists, family physicians, pediatricians, psychiatrists or neurologists. The treatments forADHD may involve pharmacotherapy and nonpharmacologic therapy, including such interventions as individualand/or family psychotherapy.POLICYServices for the assessment or treatment of attention-deficit/hyperactivity disorder (ADHD) donot require prior authorization if covered.Procedure code 96127 may only be billed with a limit of two units per date of service.Refer to these medical policies for coverage determinations: PG0035 Outpatient Advanced Imaging Authorization - (70554, 70555 & 96020)PG0338 – 12/21/2020

PG0150 Chiropractic Services & Spinal Manipulation – (98940-98943)PG0198 Actigraphy and Accelerometry – (95803)PG0294 Transcranial Magnetic Stimulation TMS – (90867 & 90868)PG0335 Children's Intensive Behavioral Service/Applied Behavioral Analysis (ABA) (9615096155)COVERAGE CRITERIAHMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, AdvantageServices provided by a psychiatrist, psychologist or other behavioral health professionals may be subject to theprovisions of the applicable behavioral health benefit.Assessment and 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.Services for the assessment or treatment of attention-deficit/hyperactivity disorder (ADHD) that are consideredprimarily educational or training in nature or focused on improving academic or work performance are not coveredunder many benefit plans.When not otherwise excluded, Paramount covers medically necessary services for the treatment of ADHD whenthe criteria of the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) are met.Coverage of medications related to the treatment of ADHD is subject to the pharmacy benefit of the applicablebenefit plan.Paramount does not cover any of the following services, because each is considered educational in nature and/ornot medically necessary for the assessment and/or treatment of ADHD (this list may not be all-inclusive): Intelligence Quotient (IQ) testing education and achievement testing educational intervention (e.g., classroom environmental manipulation, academic skills training, and parentaltraining) neuropsychological testingParamount does not cover the following procedures/services, because each is considered experimental,investigational or unproven for the assessment and/or treatment of ADHD (these lists may not be all-inclusive):Assessment: actometer computerized electroencephalogram (EEG) (e.g., brain mapping, neurometrics, or quantitativeelectroencephalography [QEEG], Neuropsychiatric EEG-Based Assessment Aid [NEBA] System) computerized tests of attention and vigilance event-related potentials (i.e., evoked potential studies) hair analysis neuroimaging (e.g., computerized tomography [CT], magnetic resonance imaging [MRI], positron emissiontomography [PET] and single-photon emission computerized tomography [SPECT]) Quotient ADHD Test/SystemTreatment: acupuncture/acupressure anti-candida albicans and antifungal medications anti-motion sickness medication auditory integration therapy chiropractic manipulation cognitive rehabilitation dietary treatments Dore program/Dyslexia Dyspraxia Attention Treatment (DDAT) EEG biofeedback/neurofeedbackPG0338 – 12/21/2020

herbal 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 therapyCODING/BILLING INFORMATIONThe appearance of a code in this section does not necessarily indicate coverage. Codes that are covered mayhave selection criteria that must be met. Payment for supplies may be included in payment for other servicesrendered.CPT CODES70450 Computed tomography, head or brain; without contrast material70460 Computed tomography, head or brain; with contrast material(s)Computed tomography, head or brain; without contrast material, followed by contrast material(s) and70470further sectionsComputed tomographic angiography, head, with contrast material(s), including noncontrast images, if70496performed, and image postprocessing70544 Magnetic resonance angiography, head; without contrast material(s)70545 Magnetic resonance angiography, head; with contrast material(s)Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s)70546and further sequences70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material70552 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material,70553followed by contrast material(s) and further sequencesMagnetic resonance imaging, brain, functional MRI; including test selection and administration of70554 repetitive body part movement and/or visual stimulation, not requiring physician or psychologistadministrationMagnetic resonance imaging, brain, functional MRI; requiring physician or psychologist70555administration of entire neurofunctional testing76390 Magnetic resonance spectroscopy78600 Brain imaging, less than 4 static views;78601 Brain imaging, less than 4 static views; with vascular flow78605 Brain imaging, minimum 4 static views;78606 Brain imaging, minimum 4 static views; with vascular flow78607 Brain imaging, tomographic (SPECT)78608 Brain imaging, positron emission tomography (PET); metabolic evaluation78609 Brain imaging, positron emission tomography (PET); perfusion evaluation90791 Psychiatric diagnostic evaluation90792 Psychiatric diagnostic evaluation with medical services90832 Psychotherapy, 30 minutes with patient and/or family memberPsychotherapy, 30 minutes with patient and/or family member when performed with an evaluation90833and management service (List separately in addition to the code for primary procedure)90834 Psychotherapy, 45 minutes with patient and/or family memberPsychotherapy, 45 minutes with patient and/or family member when performed with an evaluation90836and management service (List separately in addition to the code for primary procedure)90837 Psychotherapy, 60 minutes with patient and/or family member90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluationPG0338 – 12/21/2020

961219612596127and management service (List separately in addition to the code for primary procedure)Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including corticalmapping, motor threshold determination, delivery and managementTherapeutic repetitive transcranial magnetic stimulation (TMS) treatment;; subsequent delivery andmanagement, per sessionOrthoptic and/or pleoptic training with continuing medical direction and evaluationComputerized dynamic posturographyActigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14consecutive days of recording)Electroencephalogram (EEG) extended monitoring; 41-60 minutesElectroencephalogram (EEG) extended monitoring; greater than 1 hourElectroencephalogram (EEG); including recording awake and drowsyElectroencephalogram (EEG); including recording awake and asleepElectroencephalogram (EEG); all night recordingVisual evoked potential (VEP) checkerboard or flash testing, central nervous system exceptglaucoma, with interpretation and reportDigital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)Neurofunctional testing selection and administration during noninvasive imaging functional brainmapping, with test administered entirely by a physician or other qualified healthcare professional (i.e.psychologist), with review of test results and reportPsychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities,personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's orphysician's time, both face-to-face time administering tests to the patient and time interpreting thesetest results and preparing the reportPsychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities,personality and psychopathology, eg, MMPI and WAIS), with qualified health care professionalinterpretation and report, administered by technician, per hour of technician time, face-to-facePsychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities,personality and psychopathology, eg, MMPI), administered by a computer, with qualified health careprofessional interpretation and reportNeurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquiredknowledge, attention, language, memory, planning and problem solving, and visual spatial abilities),per hour of the psychologist's or physician's time, both face-to-face time with the patient and timeinterpreting test results and preparing the reportNeuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler MemoryScales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, bothface-to-face time administering tests to the patient and time interpreting these test results andpreparing the report (Deleted code effective 12/31/18)Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler MemoryScales and Wisconsin Card Sorting Test), with qualified health care professional interpretation andreport, administered by technician, per hour of technician time, face-to-face (Deleted code effective12/31/18)Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, withqualified health care professional interpretation and report (Deleted code effective 12/31/18)Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquiredknowledge, attention, language, memory, planning and problem solving, and visual spatial abilities),by physician or other qualified health care professional, both face-to-face time with the patient andtime interpreting test results and preparing the report; each additional hour (List separately in additionto code for primary procedure) (New code effective 01/01/2019)Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hourof a qualified health care professional's time, both face-to-face time administering tests to the patientand time interpreting these test results and preparing the reportBrief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivitydisorder [ADHD] scale), with scoring and documentation, per standardized instrumentPG0338 – 12/21/2020

Health and behavior assessment (eg, health-focused clinical interview, behavioral observations,96150 psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face withthe patient; initial assessmentHealth and behavior assessment (eg, health-focused clinical interview, behavioral observations,96151 psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face withthe patient; re-assessment96152 Health and behavior intervention, each 15 minutes, face-to-face; individual96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)96155 Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present)Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning,executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to97127manage the performance of an activity (eg, managing time or schedules, initiating, organizing andsequencing tasks), direct (one-on-one) patient contactDevelopment of cognitive skills to improve attention, memory, problem solving (includes97532 compensatory training), direct (one-on-one) patient, each 15 minutes (Deleted code effective12/31/17)Sensory integrative techniques to enhance sensory processing and promote adaptive responses to97533environmental demands, direct (one-on-one) patient contact, each 15 minutes98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions98942 Chiropractic manipulative treatment (CMT); spinal, five regions98943 Chiropractic manipulative treatment (CMT); extraspinal, one or more regionsREVISION HISTORY EXPLANATIONORIGINAL EFFECTIVE DATE: 07/14/201507/14/15: Policy created to reflect most current clinical evidence per Medical Policy Steering Committee.12/12/17: Effective 12/31/17 deleted code 97532. Revised effective 01/01/2018 code 95930. Added effective01/01/18 new code 97127. Policy reviewed and updated to reflect most current clinical evidence per MedicalPolicy Steering Committee.01/08/19: Effective 12/31/18 deleted codes 96118, 96119, & 96120. Revised effective 01/01/2019 code 96116.Added effective 01/01/19 new code 96121. Policy reviewed and updated to reflect most current clinical evidenceper Medical Policy Steering Committee.12/21/2020: Medical policy placed on the new Paramount Medical Policy FormatREFERENCES/RESOURCESCenters for Medicare and Medicaid Services, CMS Manual System and other CMS publications and servicesOhio Department of MedicaidAmerican Medical Association, Current Procedural Terminology (CPT ) and associated publications and servicesCenters for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Releaseand Code SetsIndustry Standard ReviewHayes, Inc.PG0338 – 12/21/2020

Mental Disorders (DSM-5), published by the American Psychiatric Association (APA). The DSM-5 includes a set of diagnostic criteria that indicate the symptoms that must be present to establish the diagnosis of ADHD. There are several types of specialists qualified to

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