Sec. 31.10.39.03. Utilization Review Criteria for Treatment of Autism and Autism Spectrum Disorders

A. The utilization review criteria of a carrier or private review agent acting on behalf of a carrier to determine medical necessity or appropriateness may not be more restrictive for habilitative services for the treatment of autism and autism spectrum disorders than the criteria listed in this regulation.

B. The carrier’s criteria for habilitative services shall include criteria for behavioral health treatment, psychological care, and therapeutic care.

C. Utilization review criteria of a carrier or private review agent acting on behalf of a carrier may require:

(1) A comprehensive evaluation of a child by the child’s primary care provider or specialty physician identifying the need for habilitative services for the treatment of autism or autism spectrum disorder;

(2) A prescription from a child’s primary care provider or specialty physician that includes specific treatment goals; and

(3) An annual review by the prescribing primary care provider or specialty physician, in consultation with the habilitative services provider, that includes:

(a) Documentation of benefit to the child;

(b) Identification of new or continuing treatment goals; and

(c) Development of a new or continuing treatment plan.

D. A carrier or private review agent acting on behalf of a carrier may not deny coverage based solely on the number of hours of habilitative services prescribed, for:

(1) Less than or equal to 25 hours per week in the case of a child who is at least 18 months of age and who has not reached the child’s sixth birthday, or

(2) Less than or equal to 10 hours per week in the case of a child who has reached the child’s sixth birthday and who has not reached the child’s nineteenth birthday.

(3) Notwithstanding §D(1) and (2) of this regulation, a carrier may authorize additional hours of habilitative services that are medically necessary and appropriate for the treatment of autism or autism spectrum disorders.

E. A carrier may limit payment for habilitative services to payment for services provided by individuals who are licensed, certified, or otherwise authorized under the Health Occupations Article or similar licensing, certification, or authorization requirements of another state or U.S. territory where the habilitative services are provided.

F. Location of services.

(1) A carrier may not deny payment for habilitative services if a treatment goal identifies the location of the habilitative services as the child’s educational setting.

(2) Nothing in §F(1) of this regulation shall be construed to require a carrier to provide services to a child under an individualized education program or any obligation imposed on a public school by the Individuals With Disabilities Education Act, 20 U.S.C. 1400 et seq., as amended from time to time.

G. A carrier or a private review agent acting on behalf of a carrier may not deny payment for applied behavior analysis on the basis that it is experimental or investigational.