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Comprehensive Diagnostic Evaluations, or comparable substitutes, must include evidence of the following:
- A completed neurodevelopmental review of cognitive, behavioral, emotional, adaptive, and social functioning. This assessment should include validated evaluation tools (e.g., ADOS, CARS, GARS, etc.) used to diagnose and recommend general ASD treatment interventions. The results of this evaluation, including an ASD diagnosis if applicable, should be documented in an evaluation report.
- The evaluation must be conducted by a fully licensed practitioner, such as a psychiatrist, neurologist, pediatrician, psychologist, licensed clinical social worker, licensed professional counselor, or licensed marriage and family therapist. The practitioner must be operating within the scope of their practice and must possess the necessary qualifications and experience to provide ASD evaluation services.
- Recommendations for ASD services should be based on a diagnosis consistent with the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM 5) definition of autism spectrum disorder.
- The primary purpose of the evaluation cannot be exclusively for educational, vocational, or legal purposes.
If the Comprehensive Diagnostic Evaluation leading to the member’s ASD diagnosis was conducted more than 12 months ago, a letter from a current treating licensed provider confirming the ASD diagnosis is required. This letter must be dated within the last 12 months.
Additionally, when seeking authorization of ASD services for members under three years of age, there must be demonstrated clinical evidence that Birth to Three (3) services have previously been explored and exhausted. This clinical rationale should be documented in the request for authorization of behavior assessment and/or ASD treatment services submitted to CT BHP.
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