95815
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the individual meets DSM-5 TR criteria for Autism Spectrum Disorder when behavioral health treatment is requested
- Behavioral health evaluation / psychiatric diagnostic evaluation report (CPT 90791 / 90792) when applicable
- Results and documentation of autism-specific developmental screening instruments (CPT 96110) and developmental test administration/interpretation reports (CPT 96112, 96113) when those services are billed
- EEG report and clinical documentation supporting 'suspicion of a seizure' when EEG is performed
Key Coverage Criteria
- Behavioral health evaluation including psychiatric examination for suspected or known ASD
- Electroencephalogram (EEG) when there is suspicion of a seizure
- Evaluation by speech and language pathologist
- Lead screening (CPT 83655)
- Autism-specific developmental screening (CPT 96110, e.g., CHAT, PDDST-II) and developmental tests (CPT 96112, 96113 e.g., ABC, CARS)
- Neuroimaging studies when the child is a candidate for specific interventions such as epilepsy surgery
1 Active Policy
CIGNA-0447 — Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447)
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