The Delaware State Autism Mandate (18 Del. C. Sections 3361 and 3570A)

For new plans and those renewing after December 11, 2012, Delaware law now requires coverage for Autism Spectrum Disorders (ASD).  The application of this mandate is limited to individual and group coverage that is subject to Delaware insurance law (insured business).

The Delaware Autism Mandate (18 Del. C. Sections 3361 and 3570A) requires coverage for the medically necessary screening, diagnosis and treatment of ASD by Autism Services Providers for individuals less than 21 years of age.  The mandate specifically requires coverage for Applied Behavioral Analysis (ABA) as described below.

• Coverage may not be denied on the basis that the treatment is habilitative or nonrestorative in nature.

Coverage shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health benefit plan, except as otherwise provided for regarding ABA therapy (discussed below).

Coverage for applied behavior analysis services an insurer shall be subject to a maximum benefit of $36,000 per 12 month period, but shall not be subject to any limits on the number of visits an individual may make to an autism services provider or that a provider may make to an individual regardless of the locations in which services are provided.

Coverage for physical medicine is determined according to individual or group customer benefits.

Physical medicine is a covered service when performed with the expectation of restoring the individual's level of function that has been lost or reduced by injury or illness.

Treatment plans must be maintained in the medical record, and made available upon request.

A typical session usually consists of up to one (1) hour of rehabilitative therapy which could include up to four (4) physical medicine modalities/procedures and/or units performed on the same date of service, per performing provider.

Reimbursements for physical therapy (PT)/occupational therapy (OT) visits involving any of the physical medicine procedures are limited as follows:

• Up to four (4) codes/units in any combination per date of service per performing provider.
• Payment will be based on the highest submitted and allowed physical medicine codes.
  • Modalities 97012-97039, G0283, S8950
  • Therapeutic procedures  97110-97542
  • Tests and measurements 97750
  • Muscle range of motion (ROM) testing  95851-95852
  • Orthotic management and prosthetic management  97760-97763

Services exceeding the limitation will be considered not medically necessary.

Duplicate therapy is not considered medically necessary.

Physical Medicine Evaluation

Evaluation and Management (E&M) service is considered an inherent part of a physical medicine evaluation. The E&M service is not eligible for separate payment when reported on the same day as a physical medicine evaluation.

When an E&M service is reported in conjunction with a physical medicine evaluation the services must be combined under the appropriate code for the physical medicine evaluation.

Modifier "-25" may be reported with medical care (e.g. E&M visits, consultations) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier "-25" is reported, the patient’s medical records must clearly document that separately identifiable medical care was rendered.

Muscle testing, ROM testing, and physical performance testing are considered components of a physical medicine evaluation and are not eligible for separate payment when billed on the same date of service as a physical medicine evaluation.

Modifier "-59" may be reported with a non-E&M service, to identify it as distinct or independent from other non-E&M services performed on the same day.

Maintenance Therapy
Physical medicine services performed repetitively to maintain a level of function are not eligible for reimbursement unless the member has Habilitative services benefits.

A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. These service  would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur. Maintenance therapy should be reported under procedure code S8990 (physical or manipulative therapy performed for maintenance rather than restoration), and is not eligible for reimbursement.

Habilitative Therapy 
Habilitative therapy services ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Habilitative/Rehabilitative therapy services must be reported with the 96 or 97 modifiers in conjunction with the appropriate therapy code.

Habilitative therapy is not eligible for payment, unless the member has a habilitative benefit.

*Spinal manipulation is not considered an habilitative service.

Supervised Modalities 
Supervised modalities do not require direct one-on-one contact by the provider. These are not time-based codes.

Vasopneumatic Compression
Vasopneumatic compression  treatment is warranted for the following conditions:

• Edema of the extremities
• Hematoma of the leg
• Lymphedema of the arm
• Lymphedema of the leg
• Venous insufficiency or venous stasis disorder

Conditions other than those listed above or indicate that an infection is present will be denied as not medically necessary.

Vasopneumatic compression service is considered a supervised modality and is not considered time-based. It should be reported only once per treatment session, regardless of the number of areas treated or the length of time required to complete treatment.

Services provided by devices that provide both vasopneumatic compression and cold therapy simultaneously, should be reported with code 97016.

Infrared Therapy 
The use of infrared and near-infrared light and heat, including monochromatic infrared energy, is considered not medically necessary when used as a physical medicine modality for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues.

Constant Attendance Modalities
Constant attendance modalities require direct one-on-one patient contact by the provider. Documentation must include the amount of time spent in providing all aspects of this service.

When two (2) constant attendance modalities are performed at the same time, using one (1) device, the code representing the primary modality can be reported.

Aquatic Therapy 
Aquatic therapy must be performed with the expectation of restoring a patient's level of function that has been lost or reduced by injury or illness. Aquatic therapy performed to maintain a level of function is considered to be a maintenance program and is not eligible for reimbursement.

A provider must have direct (one to one) patient contact when reporting aquatic therapy.

Before beginning an aquatic therapy program, the provider must prepare a treatment plan that includes short-term and long-term goals that the patient can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.

Separate payment will not be made for whirlpool or Hubbard tank in addition to aquatic therapy with therapeutic exercise for a single patient encounter.

Gait Training
Accepted indications for gait training include, but are not limited to;

• Foot drop resulting from stroke
• Herniated disc(s)
• Ankle, knee and/or hip replacement
• Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the patient's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity.

• Procedure code 97116 should not be used to report orthotics or prosthetics training.
• Orthotics training should be reported using procedure codes 97760 and 97763.
• Prosthetics training should be reported using procedure codes 97761 and 97763.

Vestibular Rehabilitation Therapy
A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, patients remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for patients with vertigo, disequilibrium, and balance deficits related to the following conditions:

• Peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss),
• Mixed {peripheral and central vestibular disorders, and
• Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury)

If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary.

Not Medically Necessary

• Dry Hydro Massage

Experimental/Investigational and, therefore, non-covered, because the safety and effectiveness are not supported by current literature.

• Electromagnetic Stimulation
• Equestrian/Hippotherapy
• Low-Intensity Pulsed Ultrasound (Hands-Free Ultrasound)
• Horizontal Therapy
• Low-Level Laser Therapy (Cold Laser Therapy)
• Phonophoresis

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Physical medicine is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.