Clinical Policy Bulletin: Early Intervention Programs
Note: There are several states, which mandate benefits for early intervention programs. Some specific plan sponsors may offer benefits for these services. Coverage of component services of the intervention programs such as speech therapy, physical therapy and occupational therapy will be extended when the child presents with an eligible condition.
An early intervention program is coordinated multi-disciplinary care that involves combinations of traditional therapies such as physical, occupational and/or speech therapy, psychological counseling for families, nursing care, and physical or social stimulation for children from infancy to 3 years of age who have developmental delays or have a high potential for developmental delay. The duration of therapy may last for months or years depending on the deficits of the child and the needs of the family. Clear documentation of the efficacy of these treatment programs remains to be determined.
According to the Education of the Handicapped Act Amendments, federal legislation requires that each child recognized as having a disability that interferes with learning from infancy to age 3 have a written plan of service, an IFSP, (Individual Family Service Plan). An IFSP includes specific early intervention services that the family and child will receive and a projection of their duration. The law requires each state to create its own definition of developmental delay as a basis for determining eligibility of services. Services are provided not only for children with developmental delays, but also for those with biological conditions that may predispose to a delay. Additionally, states may provide services to children who may be at risk of developing developmental delays attributable to environmental factors. All states have established early intervention programs for children from birth to 3 years.
Gonzalez and colleagues (2012) summarized the evidence published on treatments for bipolar disorder, particularly on psychological interventions in its early phases; and provided a description of the Jano Intervention and Research Program on the Early Phases of Bipolar Disorder, which is being developed at Valdecilla Hospital (Santander, Spain). First, these investigators reviewed the data from randomized controlled trials and systematic reviews regarding 4 psychotherapies proven to be effective in the treatment of bipolar disorder: (i) psychoeducation, (ii) cognitive-behavioral therapy, (iii) family therapy and (iv) interpersonal and social rhythm therapy. Second, they displayed a systematic review on the effectiveness of psychological therapies during the early stage of bipolar disorder. Out of 456 studies, all were excluded due to not meeting the inclusion criteria. Finally, these researchers outlined the Jano Program, which provides psychiatric management, psychoeducation, psychotherapy and family therapy for patients in the early stage of bipolar disorder. Several standardized clinical, social and neuropsychological tests are administered to the patients at the beginning of the program, and also at 2, 4, 6 and 8 weeks, 3 and 6 months, 1, 2, 3 and 5 years later. The authors concluded that it is necessary to enlarge the sample and finish their data collection in order to determine the effectiveness and efficiency of this kind of program, and specially of its psychological components. They stated that early intervention for bipolar disorder may need to be adapted in some way from usual treatments to better reach their goals.
Fernell et al (2011) evaluated autism spectrum disorders (ASD) outcome in a large naturalistic study. A total of 208 children, aged 20 to 54 months, with a clinical diagnosis of ASD were given intervention and monitored prospectively in a naturalistic fashion over a period of 2 years. The toddlers were considered representative of all but the most severely multiple disabled pre-school children with ASD in Stockholm county. They fell into 3 cognitive subgroups: (i) one with learning disability, (ii) one with developmental delay, and (iii) one with normal intellectual functioning. Data on intervention type and intensity were gathered prospectively in a systematic fashion. Intervention was classified into intensive applied behavior analysis (ABA) and non-intensive, targeted interventions, also based on ABA principles. Children were comprehensively assessed by a research team before the onset of intervention, and then, again, 2 years later. Change in Vineland adaptive behavior scales (VABS) composite scores from intake (T1) to leaving the study (T2) was set as the primary outcome variable. The research team remained blind to the type and intensity of interventions provided. One hundred and ninety-eight (95 %) of the original samples stayed in the study throughout the whole 2-year period and 192 children had a complete Vineland composite score results both at T1 and T2. Vineland composite scores increased over the 2-year period. This increase was accounted for by the subgroup with normal cognitive functioning. There was no significant difference between the intensive and non-intensive groups. Individual variation was considerable, but no child in the study was "problem-free" at follow-up. The authors concluded that these findings do not support that children with ASD generally benefit more from the most intensive ABA intervention programs than from less intensive interventions or targeted interventions based on ABA.
Freitag et al (2012) noted that different early intervention programs, developed predominantly in the United States, for pre-school aged children with ASD have been published. Several systematic review articles including a German Health Technology Assessment on behavioral and skill-based early interventions in children with ASD reported insufficient evidence and a substantial problem of generalisability to the German context. In Germany, approximately 2 to 5 hrs early intervention is supported by social services. Here, these investigators reported the results of a 1 year pre-post pilot study on a developmentally based social pragmatic approach, the Frankfurt Early Intervention program (FFIP). In FFIP, individual 2:1, behaviorally and developmentally based therapy with the child is combined with parent training and training of kindergarten teachers. Treatment frequency is 2 hrs/week. Outcome measures were the VABS II, mental age and the ADOS severity score. Improvements after 1 year were observed for the VABS II socialization scale and the mental age quotient/IQ (medium effect sizes). Results were comparable with several other studies with a similar or slightly higher therapeutic intensity implementing comparable or different early intervention methods or programs. The authors concluded that compared to most high-intensity programs (30 to 40 hrs/week), lower cognitive gains were observed. They stated that results have to be replicated and assessed by a randomized controlled study before any final conclusions can be drawn.
Eapen et al (2013) evaluated the effectiveness of the Early Start Denver Model (ESDM) for preschool-aged children with ASD using a predominantly group-based intervention in a community child care setting. Participants were 26 children (21 males) with ASD with a mean age of 49.6 months. The ESDM, a comprehensive early intervention program that integrates applied behavior analysis with developmental and relationship-based approaches, was delivered by trained therapists during the child's attendance at a child care center for preschool-aged children with ASD. Children received 15 to 20 hours of group-based, and 1 hour of 1-to-1, ESDM intervention per week. The average intervention period was 10 months. Outcome measures were administered pre- and post-intervention, and comprised a developmental assessment - the Mullen Scales of Early Learning (MSEL); and two parent-report questionnaires - the Social Communication Questionnaire (SCQ) and Vineland Adaptive Behaviors Scales--Second Edition (VABS-II). Statistically significant post-intervention improvements were found in children's performance on the visual reception, receptive language and expressive language domains of the MSEL in addition to their overall intellectual functioning, as assessed by standardized developmental quotients. Parents reported significant increases in their child's receptive communication and motor skills on the VABS-II, and a significant decrease in autism-specific features on the SCQ. These effects were of around medium size, and appeared to be in excess of what may have been expected due to maturation. Nonetheless, these results need to be confirmed in a controlled study. The authors concluded that the findings of this study suggested community dissemination of ESDM using predominantly group-based intervention may be an effective intervention. Making ESDM accessible to the wider ASD community in child care settings has the potential for significant clinical and economic benefits. Moreover, they stated that further studies are indicated in this area, including those with younger children, and which incorporate a control group and standardized ASD assessments.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT code not covered for indications listed in the CPB:
Other CPT codes related to the CPB:
97110 - 97546
HCPCS codes not covered for indications listed in the CPB:
Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service
Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99600 can be used)
Nursing care, in the home; by licensed practical nurse, per hour
Speech therapy, in the home, per diem
Occupational therapy, in the home, per diem
Physical therapy; in the home, per diem
Private duty/independent nursing service(s)-licensed, up to 15 minutes
RN services, up to 15 minutes
LPN/LVN services, up to 15 minutes
Other HCPCS codes related to the CPB:
Development testing, with interpretation and report, per standardized instrument form
ICD-9 codes not covered for indications listed in the CPB:
315.00 - 315.9
Specific delays in development
Lack of normal physiological development, unspecified
Problems with learning
Problems with communication (including speech)
V79.2 - V79.9
Special screening for mental retardation, developmental handicaps in early childhood, or other and unspecified mental disorders and developmental handicaps
The above policy is based on the following references:
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Yu JW, Buka SL, McCormick MC, et al. Behavioral problems and the effects of early intervention on eight-year-old children with learning disabilities. Matern Child Health J. 2006;10(4):329-338.
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Fernell E, Hedvall Å, Westerlund J, et al. Early intervention in 208 Swedish preschoolers with autism spectrum disorder. A prospective naturalistic study. Res Dev Disabil. 2011;32(6):2092-2101.
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Gonzalez S, Artal J, Gomez E, et al. Early intervention in bipolar disorder: The Jano program at Hospital Universitario Marqués de Valdecilla. Actas Esp Psiquiatr. 2012;40(2):51-56.
Freitag CM, Feineis-Matthews S, Valerian J, et al. The Frankfurt early intervention program FFIP for preschool aged children with autism spectrum disorder: A pilot study. J Neural Transm. 2012;119(9):1011-1021.
Eapen V, Rn Ec R, Walter A. Clinical outcomes of an early intervention program for preschool children with Autism Spectrum Disorder in a community group setting. BMC Pediatr. 2013;13(1):3.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.