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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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American Academy of Pediatrics: Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering

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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders -- Fifth Edition.

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Centers for Disease Control and Prevention (CDC). Attention Deficit/Hyperactivity Disorder. Symptoms and

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Accessed February 12, 2019.

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.

https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml.

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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.