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Clinical Policy Title: Attention deficit hyperactivity disorder — diagnosis and
treatment
Clinical Policy Number: CCP.1031
Effective Date: December 1, 2013
Initial Review Date: June 16, 2013
Most Recent Review Date: May 7, 2019
Next Review Date: April 2020
Related policies:
None.
ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’s
clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’s clinical policies are not guarantees of payment.
Coverage policy
AmeriHealth Caritas considers the evaluation of children and adults for possible attention deficit
hyperactivity disorder by appropriately trained mental health professionals and primary care providers and
its treatment with behavioral therapy, including family and classroom therapies, and prescription stimulant
medication management, to be clinically proven and, therefore, medically necessary (American Academy of
Pediatrics, 2011; Gayleard, 2017; Joseph, 2017; Knouse, 2017; Luan, 2017; Liu, 2017; Otasowie, 2014).
AmeriHealth Caritas considers neurobiofeedback to be a potential alternate treatment option for members
with attention deficit hyperactivity disorder symptoms who meet any of the following criteria (Riesco-
Matías, 2019):
Member does not improve with behavioral therapy and stimulants, or
Member is intolerant of, or experiences adverse effects from, pharmacological treatment, or
Treatment with stimulants is not a preferred option.
Limitations:
Policy contains:
• Continuous performance testing.
• Guidelines of diagnosis and
medication.
• Quotient ADHD testing.
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Neurobiofeedback sessions beyond 30 treatments require review by a medical director.
AmeriHealth Caritas considers the use of the Quotient ADHD System test and the employment of
continuous performance testing by non-mental health professionals to be investigational, as the
effectiveness of their use has not been established in peer-reviewed professional literature and, therefore,
they are prohibited from coverage by state and/or federal laws and/or regulatory requirements.
Alternative covered services:
A primary care provider or a network mental health professional can make the diagnosis of attention deficit
hyperactivity disorder. Typically these same providers are able to effectively manage the child or adult with
attention deficit hyperactivity disorder.
Background
The American Academy of Pediatrics (2011) indicates that attention deficit hyperactivity disorder is the
most common neurodevelopmental disorder of childhood. In the United States in 2016, according to
parental reports, about 9.4 percent of children ages 2 – 17 years, or 6.1 million children, had ever received
a diagnosis of attention deficit hyperactivity disorder (Danielson, 2018). Attention deficit hyperactivity
disorder is generally diagnosed in childhood and may persist into adulthood. An estimated 50 percent of
cases occur post-adolescence.
Attention deficit hyperactivity disorder is characterized by both difficulty in focusing on tasks and
impulsivity. Hyperactivity (or hyperkinesis) is commonly a part of the condition, but is not a necessary
finding for the diagnosis. Diagnostic criteria for attention deficit hyperactivity disorder from the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013) are
included in Appendix A. There is no known cause of attention deficit hyperactivity disorder (National
Institute of Mental Health, 2016).
Diagnosis
The diagnosis of attention deficit hyperactivity disorder is most commonly made by primary care providers
using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(American Psychiatric Association, 2013). Children are evaluated at the request of parents, teachers, or
counselors who suspect the diagnosis and observe externalizing behaviors, such as impulsivity,
disruptiveness, or hyperactivity. In the evaluation of a child for attention deficit hyperactivity disorder, the
primary care clinician should include assessment for other conditions that might coexist with attention
deficit hyperactivity disorder, including emotional or behavioral (e.g., anxiety, depressive, oppositional
defiant, and conduct disorders); developmental (e.g., learning and language disorders or other
neurodevelopmental disorders); and physical (e.g., tics, sleep apnea) conditions (American Academy of
Pediatrics, 2011). Neuropsychological testing is not necessary for diagnosis or treatment of attention deficit
hyperactivity disorder, and is more useful for research purposes (Lange, 2014).
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Tests used in assessing for attention deficit hyperactivity disorder include the Controlled Oral Word
Association Test, Rey-Osterrieth Complex Task, Stroop Color and Word Test, Trail Making Test, Wisconsin
Card Sorting Test, Freedom from Distractibility Index, Wide Range Assessment of Memory and Learning,
Test of Variables of Attention, Conners’ Continuous Performance Test, and Gordon Diagnostic System. A
more recent test, the Quotient ADHD System, has been marketed to primary care providers for diagnosis
and ongoing clinical assessment for both children and adults. However, studies in the 1990s suggested that
performance of psychological inventories could be used as a gauge of effectiveness of therapy. Subsequent
experience and studies have not demonstrated superiority of use of psychological testing or of tests such as
the Quotient Rx or continuous performance test over clinical assessment alone in final outcomes. As such,
the role of these tests in final outcomes is not clear. Neither the American Academy of Pediatrics nor the
American Academy of Child and Adolescent Psychiatry guidelines recommend the use of such psychological
inventories for diagnosis or management of attention deficit hyperactivity disorder.
Treatment
The cornerstones of treatment for attention deficit hyperactivity disorder are education and support of
parents, appropriate school placement, behavioral therapy, and FDA-approved prescription medications
(American Academy of Child and Adolescent Psychology, 2007). Evidence-based studies have demonstrated
improvement in attention deficit hyperactivity disorder-associated behavior with behavioral parent training
that helps the child regulate his or her own behavior. Behavioral therapy techniques used in the classroom
have also been helpful in managing the child’s behavior in a classroom setting.
Drug management relies on the use of stimulant medications that have the paradoxical effect of reducing
the hyperactivity component, allowing the child to better focus. Recommendations for medication
treatment include first-line use of stimulants, consideration of extended-release alpha 2-adrenergic
agonists concurrently, and atomoxetine as an alternative for patients who cannot tolerate stimulants. Two
extended-release alpha 2-agonists are Food and Drug Administration-approved for treatment of attention
deficit hyperactivity disorder in children ages 6 – 17 years. Recent research has focused on the efficacy of
tricyclic antidepressants in the treatment of attention deficit hyperactivity disorder. There is some
evidence, of good quality, that this class of drugs may be helpful as an alternative to currently prescribed
and FDA-approved medications in the treatment of attention deficit hyperactivity disorder. However,
concerns persist regarding side effects of stimulant drugs, such as delayed growth, suicidal ideation, tics,
substance abuse, seizures, hypertension, prolonged QT interval, and rare reports of sudden death.
Monitoring of growth, blood pressure, and cardiac symptoms is important.
The American Academy of Pediatrics (2011) recommends development of a communication system
between the treating provider, patient, family, and school or social systems to maximize the effectiveness
of treatment.
Searches
AmeriHealth Caritas searched PubMed and the databases of:
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UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality and other evidence-based practice centers.
The Centers for Medicare & Medicaid Services.
We conducted searches on February 12, 2019. Search terms were: “attention deficit,” “attention deficit
hyperactivity disorder,” “hyperactivity,” “diagnosis,” and “treatment.”
We included:
Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and
greater precision of effect estimation than in smaller primary studies. Systematic reviews use
predetermined transparent methods to minimize bias, effectively treating the review as a
scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies
— which also rank near the top of evidence hierarchies.
Findings
The preponderance of medical evidence supports a conclusion that the evaluation of children and adults for
attention deficit hyperactivity disorder by appropriately trained mental health professionals and primary
care providers, and its treatment with behavioral therapy, including family and classroom therapies, and
prescription stimulant medication management, is a clinically proven methodology for safe practice.
Policy updates:
A narrative review (Bied, 2017) considered the psychometric properties of parent and teacher informants
relative to attention deficit hyperactivity disorder diagnosis in pediatric populations. The diagnostic
accuracy for predicting attention deficit hyperactivity disorder diagnoses did not differ between parents
and teachers. Sample size, sample type, participant drop-out, participant age, participant gender,
geographic location, and date of study publication were assessed as potential confounds. Parent reports
were statistically indistinguishable from those of teachers. The authors concluded that both parents and
teachers may yield moderate to good diagnostic accuracy for attention deficit hyperactivity disorder
diagnoses.
In the 2018 review, we added 30 peer-reviewed publications to the reference list. Of these, we added 11 to
the summary of clinical evidence. We did not add any publications in the guideline/other category. Also of
note, a study previously included in the summary of clinical evidence was removed from this table because
the Cochrane Collaboration determined that the literature that it was based on had numerous
shortcomings, and that the review’s methods and conclusions were flawed (Boesen, 2017; Epstein, 2014).
In the 2019 update, we added one guideline/other and 13 peer-reviewed publications to the reference list.
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Seven of these center on or include the topic of neurobiofeedback, a noninvasive and
nonpharmacotherapeutic approach in which an electronic device monitors brain activity and software
sends data providing feedback. An individual can be trained, through repetition, to create voluntary
changes in brain activity based on the feedback (Marzbani, 2016).
Fiesco-Matias’ (2019) meta-analysis of seven previous meta-analyses includes 16 separate studies
of neurobiofeedback. Ten studies compared neurobiofeedback with some “nonactive” control
group such as physical activity, attention training, stimulants, tomographic electroencephalography
biofeedback, cognitive training, treatment waitlist, or no treatment; five studies compared
neurofeedback with stimulants; and one study included both types of control groups. There were
insufficient data to include a comparison of neurofeedback with behavioral treatments in the meta-
analysis. The numbers of neurofeedback sessions in the included studies ranged from 25 to 40
treatments. Fiesco-Matias found that neurofeedback has been demonstrated to be effective fairly
consistently over ten years of study. When compared with non-active control groups, the effect
sizes of the pre- and post-treatment differences were -0.33 standard mean difference (-0.56, -0.10)
using most proximal assessment, and -0.25 (-0.45, -0.04) using probably blinded assessment. When
compared with stimulants, it is less effective, with the results favoring medication. The authors
concluded that the included meta-analyses supported the efficacy of neurofeedback for the
domains of inattention and hyperactivity when data from the most-proximal evaluator on pre- and
post-treatment differences were used to figure effect sizes.
While more research with greater statistical power is needed, it appears that the duration of the
effect of neurofeedback compares favorably to nonactive control assignment (Van Doren, 2018).
The within-group standard mean differences at six months post-treatment were 0.80 (large effect
size) for inattention (increased from 0.64, a medium effect size immediately post-treatment) and
0.61 (medium effect size) for hyperactivity/impulsivity (retained from 0.80 post-treatment).
Assignment to a nonactive control condition resulted in a small effect size immediately post-
treatment, but no difference at six months. Assignment to an active stimulant treatment resulted in
a standard mean difference of 1.08 (large effect size) for the domain of inattention immediately
post-treatment, that was retained at six months follow-up (1.06 standard mean difference). In the
domain of hyperactivity/impulsivity, pharmacotherapy resulted in a standard mean difference of
0.74 (medium effect size) immediately after treatment, retained at six months follow-up (0.67). The
authors concluded that while pharmacotherapy has a greater effect, neurofeedback’s effect is more
durable than that of a non-active control condition.
In sum, while further research is needed to compare neurofeedback with active treatments, it appears that
neurobiofeedback can be considered a nonstimulant treatment choice and may be appropriate for patients
whose symptoms do not improve with stimulants, or who are intolerant of or experience adverse effects
from pharmacological treatment, or who prefer to avoid treatment with stimulants. Therefore, we are
amending the coverage policy to include neurobiofeedback as a treatment for those who are intolerant or
whose symptoms are not improved by stimulants or who have not attempted treatment with stimulants.
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The policy id changed to CCP.1031 from 09.02.03.
References
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National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder. Diagnosis and
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National Institute of Mental Health. Attention-deficit/hyperactivity disorder. March 2016.
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Centers for Medicare & Medicaid Services National Coverage Determinations:
No National Coverage Determinations identified as of the writing of this policy.
Local Coverage Determinations:
No Local Coverage Determinations identified as of the writing of this policy.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill in
accordance with those manuals.
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CPT Code Description Comment
96111 Developmental testing, (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report.
90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes
90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes
ICD-10 Code Description Comment
F90.0-F90.9 Attention-deficit hyperactivity disorders
HCPCS Level II Code
Description Comment
E0746 Electromyography (EMG), biofeedback device
Appendix A
Table 1
ADHD consists of a pattern of behavior present in multiple settings where it gives rise to social, educational
or work performance difficulties.
A. Either (A1) or (A2):
A1. Inattention
Six or more of the following symptoms of inattention have been present for at least six months to a
degree that is inconsistent with developmental level and that impact directly on social and
academic/occupational activities.
a. Often does not give close attention to details or makes careless mistakes in schoolwork,
work or other activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty
remaining focused during lectures, conversations or reading lengthy writings).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in
the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores or
duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked;
fails to finish schoolwork, household chores or tasks in the workplace).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential
tasks; difficulty keeping materials and belongings in order; messy, disorganized work; poor
time management; tends to fail to meet deadlines).
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f. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
(e.g., schoolwork or homework; for older adolescents and adults, preparing reports,
completing forms or reviewing lengthy papers).
g. Often loses things needed for tasks and activities (e.g., school materials, pencils, books,
tools, wallets, keys, paperwork, eyeglasses or mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may
include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., chores, running errands; for older adolescents and
adults, returning calls, paying bills, keeping appointments).
A2. Hyperactivity and impulsivity:
Six or more of the following symptoms of hyperactivity and impulsivity have been present for at
least six months to a degree that is inconsistent with developmental level and that impact directly
on social and academic/occupational activities.
Hyperactivity:
a. Often fidgets with hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her
place in the classroom, office or other workplace, or in other situations that require
remaining seated).
c. Often runs about or climbs in situations where it is inappropriate. (In adolescents or
adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go” or often acts as if “driven by a motor” (e.g., is unable or
uncomfortable being still for an extended time, as in restaurants, meetings, etc.; may be
experienced by others as being restless and difficult to keep up with).
f. Often talks excessively.
g. Often blurts out answers before questions have been completed (e.g., completes
people’s sentences and “jumps the gun” in conversations, cannot wait for next turn in
conversation).
h. Often has trouble waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations or games or
activities; may start using other people’s things without asking or receiving permission;
adolescents or adults may intrude into or take over what others are doing).
B. Some symptoms that cause impairment were present prior to age 12.
C. Criteria for the disorder are met in two or more settings (e.g., at home, school or work, with friends or
relatives, or in other activities).
D. There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic
or occupational functioning.
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E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder
and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder,
dissociative disorder or a personality disorder).
Specify based on current presentation:
Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are
met for the past six months.
Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-
impulsivity) is not met and three or more symptoms from Criterion A2 have been present for the past six
months.
Inattentive presentation (restrictive): If Criterion A1 (inattention) is met but no more than two symptoms
from Criterion A2 (hyperactivity-impulsivity) have been present for the past six months.
Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and
Criterion A1 (inattention) is not met for the past six months.
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no
longer meet full criteria, “in partial remission” should be specified.
ADHD not elsewhere classified may be coded in cases in which the individuals are below threshold for
ADHD or for whom there is insufficient opportunity to verify all criteria. However, ADHD-related symptoms
should be associated with impairment, and they are not better explained by any other mental disorder.