Medical policy: Medical Treatments for Autism Spectrum Disorder

Policy number: MP 2.304

Effective date: 10/1/2026

Policy

Diagnostic testing and assessment

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Services may be considered medically necessary when performed as part of a comprehensive, multidisciplinary diagnostic evaluation for Autism Spectrum Disorder (ASD) when clinically indicated.

Comprehensive Diagnostic Evaluation (CDE) may include:

• Clinical assessment by a qualified professional (e.g., developmental pediatrician, child psychologist, pediatric neurologist)
• Use of validated diagnostic instruments (e.g., ADOS-2, ADI-R)
• Developmental and behavioral history with direct observation
• Speech-language evaluation
• Audiological assessment to rule out hearing deficits
• Neuropsychological testing when clinically indicated

Other evaluations and interventions

Sensory integration therapy may be considered medically necessary when incorporated into a licensed occupational therapy plan addressing documented functional impairments.

Investigational services

The following are considered investigational for the assessment or treatment of ASD due to insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with the procedure:

• Secretin infusion (in the absence of documented pancreatic disorders)
• Sensory-friendly, weighted, or compression clothing/vests
• Intravenous chelation therapy (in the absence of heavy metal toxicity)
• Auditory integration training (AIT)
• Standalone sensory integration therapy
• Hyperbaric oxygen therapy
• Stem cell therapy
• Allergy or nutritional testing (in the absence of signs or symptoms of a specific underlying condition)
• Specialized diets (e.g., gluten-free/casein-free) when used solely to treat ASD without a diagnosed medical condition

Services covered under other medical policies

Coverage for the following services is determined under their respective policies:

• Speech therapy
• Neuropsychological testing
• Genetic testing
• Biofeedback
• Vision therapy
• Evoked potential studies

Policy guidelines

This policy does not address molecular or genetic testing for the diagnosis and assessment of ASD. These services are managed by the vendor Evicore.

Secretin infusion

Secretin is a gastrointestinal hormone that stimulates pancreatic secretion. Its use in ASD was based on a hypothesized gut-brain relationship. However, a 2012 systematic review of 16 randomized controlled trials (re-validated by subsequent Cochrane reviews through 2023) found no evidence that secretin improves core features of autism. The use of sensory friendly, weighted or compression clothing has not been thoroughly studied for the treatment of ASD.

Sensory and compression clothing

The use of weighted, compression, or sensory-friendly clothing has not been supported by high-quality clinical evidence demonstrating therapeutic benefit for core ASD symptoms.

Cross-references

• MP 2.001 Allergy Testing and Immunotherapy
• MP 2.401 Biofeedback for Miscellaneous Indications
• MP 4.005 Intravenous Chelation Therapy
• MP 4.007 Vision Therapy
• MP 4.027 Neuropsychological Testing for Medical Purposes
• MP 4.029 Evoked Potential Studies
• MP 8.002 Speech Therapy (Outpatient)
• MP 8.011 Sensory Integration and Auditory Integration Therapy

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

For fully-insured group policies, the Children’s Health Insurance Program (“CHIP”) policies, and self-funded groups that have opted to be subject to Act 62, the requirements of this policy are applied to the extent permitted by Act 62.

FEP PPO - Refer to the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

The FEP program dictates that all drugs, devices or biological products approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational. Therefore, FDA-approved drugs, devices or biological products may be assessed on the basis of medical necessity. Pennsylvania Act 62 of 2008 does not apply.

Description/background

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and social interaction across multiple contexts (e.g., difficulty with social as well as restricted, repetitive patterns of behavior, interests, or activities.

ASD presents with a wide range of severity and functional impact. Diagnosis is based on clinical evaluation using standardized criteria and validated tools.

Therapeutic approach

Management of ASD typically involves medical and developmental interventions tailored to individual needs. Not all therapies have demonstrated effectiveness in improving core symptoms, and medical necessity must be based on evidence, functional impact, and clinical benefit.

Definitions

Asperger's syndrome: A condition in which the essential features are less severe with sustained impairment in social interaction and the development of restricted, repetitive patterns of behavior, interests and activities. In contrast to autistic disorder, there are no clinically significant delays or deviance in language acquisition, although more subtle aspects of social communication may be affected. In addition, during the first 3 years of life, there are no clinically significant delays in cognitive development as manifested by expressing normal curiosity about the environment or in the acquisition of age-appropriate learning skills and adaptive behaviors (other than in social interactions).

Autistic disorder: A condition characterized by the presence of markedly abnormal or impaired development in social interaction and communication and a markedly restricted repertoire of activity and interests. The onset usually occurs within the first three years of life.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms and conditions of a member’s specific health plan. In addition, not all covered services are eligible for separate reimbursement.

**Coding list is not all inclusive. Refer to specific Medical Policy for coding, see cross references**

Covered when medically necessary

Investigational

References

1. American Academy of Pediatrics, Myers SM, Levy SE, Hyman SL. Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics. Vol. 145(1) January 2020.
2. American Academy of Pediatrics, Myers SM, Johnson CP, Committee on Children with Disabilities. Management of Children with Autistic Spectrum Disorders. Pediatrics. Vol. 120(5) October 2007.
3. Cohen H, Amerine-Dickens M, Smith T. Early intensive behavioral treatment: replication of the UCLA model in a community setting. J Dev Behav Pediatr. 2006; 27(2 Suppl):S145-155.
4. Cooper GM, Coe BP, Girirajan S et al. A copy number variation morbidity map of developmental delay. Nat Genet. 2011; 43(9):838-46.
5. Coulter ME, Miller DT, Harris DJ et al. Chromosomal microarray testing influences medical management. Genet Med. 2011; 13(9):770-6.
6. Gold C, Wigram T, Elefant C. Music therapy for autistic spectrum disorder. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004381.
7. Hyman SL, Levy SE, Myers SM. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020 Jan 1;145(1).
8. Jesner OS, Aref-Adib M, Coren E. Risperidone for autism spectrum disorder. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005040.
9. Johnson C.P, Myers, S and the Council on Children With Disabilities. Identification and Evaluation of Children with Autism Spectrum Disorders. Published online November 1, 2007. Pediatrics Vol. 120 No. 5 November 2007, pp. 1183-1215 (doi:10.1542/peds.2007-2361). Reaffirmed November 2014.
10. Novitas Solutions. Local Coverage Determination (LCD) L35101 Psychiatric Codes. Effective 10/1/15.
11. Nye C, Brice A. Combined vitamin B6-magnesium treatment in autism spectrum disorder. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003497.
12. Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, § 512, 29 U.S.C. § 1185a. Accessed May 23, 2023.
13. Pennsylvania General Assembly. Act 62 of 2008 (formerly House Bill 1150).
14. Saam J, Gudgeon J, Aston E et al. How physicians use array comparative genomic hybridization results to guide patient management in children with developmental delay. Genet Med. 2008; 10(3):181-6.
15. Schaefer GB, Mendelsohn NJ. Clinical genetics evaluation in identifying the etiology of autism spectrum disorders. Genet Med. 2008; 10(4):301-5.
16. Stankiewicz P, Beaudet AL. Use of array CGH in the evaluation of dysmorphology, malformations, developmental delay, and idiopathic mental retardation. Curr Opin Genet Dev. 2007; 17(3):182-92.
17. Subramonia-Iyer S, Sanderson S, Sagoo G et al. Array-based comparative genomic hybridization for investigating chromosomal abnormalities in patients with learning disability: systematic review meta-analysis of diagnostic and false-positive yields. Genet Med. 2007; 9(2):74-9.
18. UpToDate Online Journal [serial online]. Weissman L: Autism spectrum disorder in children and adolescents: Behavioral and educational interventions. UpToDate. Updated June 19, 2025.
19. Williams KW, Wray JJ, Wheeler DM. Intravenous secretin for autism spectrum disorder. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003495.
20. Xu G, Snetselaar LG, Jing J, Liu B, Strathearn L, Bao W. Association of food allergy and other allergic conditions with autism spectrum disorder in children. JAMA network open. 2018 Jun 1;1(2):e180279-.
21. Schaefer GB, Mendelsohn NJ. Clinical genetics evaluation in identifying the etiology of autism spectrum disorders: 2013 guideline revisions. [American College of Medical Genetics and Genomics Web site]. 03/21/2013.
22. National Institute for Health and Care Excellence: Autism spectrum disorder in adults: diagnosis and management. Last updated June 14, 2021.
23. Weissman, L, Harris, H. Autism spectrum disorder in children and adolescents: Complementary and integrative medicine therapies. UpToDate Online Journal. Updated February 11, 2026.
24. Kyriacou C, Forrester-Jones R, Triantafyllopoulou P. Clothes, Sensory Experiences and Autism: Is Wearing the Right Fabric Important? J Autism Dev Disord. 2023;53(4):1495-1508. doi:10.1007/s10803-021-05140-3.
25. Talcer MC, Duffy O, Pedlow K. A Qualitative Exploration into the Sensory Experiences of Autistic Mothers. J Autism Dev Disord. 2023;53(2):834-849. doi:10.1007/s10803-021-05188-1.
26. Pennsylvania Autism Insurance Act, HB 1150, Pa P.L. 885, No. 62 (2008) https://www.legis.state.pa.us/WU01/LI/LI/US/HTM/2008/0/0062..HTM