The following information and resources have been provided courtesy of The Lurie Center for Autism, a program of Massachusetts General Hospital and Mass General for Children.

The Lurie Center for Autism is committed to advancing treatments for and knowledge about Autism Spectrum Disorder (ASD) and other developmental disorders, and translating these discoveries into exceptional clinical care. A program of Massachusetts General Hospital and Mass General for Children, The Lurie Center is a multidisciplinary treatment, research, training, and advocacy organization dedicated to supporting individuals and their families across the lifespan.

This resource is intended to provide information so that you can be better informed. It is not a substitute for medical advice and should not be used to treat any medical conditions.

Who can diagnose Autism?

An Autism diagnosis can be made by a physician or psychologist who is experienced in the diagnosis and treatment of Autism, with developmental or child/adolescent expertise as appropriate. Most individuals receive Autism spectrum disorder (ASD) diagnoses from specialists, (i.e. Developmental Behavioral Pediatrician, Neurologist, Neuropsychologist). However, a diagnosis from a specialist is not required for insurance purposes.

What is required to make a diagnosis?

There are standardized criteria to help diagnose ASD. These are published by the American Psychiatric Association in a publication called the Diagnostic and Statistical Manual (DSM), which is currently in its fifth edition (DSM-5). View a summary of the criteria here.

Is an ASD diagnosis necessary to access autism treatments?

Yes. An Act Relative to Insurance Coverage for Autism (ARICA), the Massachusetts law, requires private insurance to cover medically necessary treatment for individuals diagnosed with Autism. MassHealth also requires an Autism diagnosis to access Applied Behavior Analysis Therapy (ABA) under the Autism Omnibus Law. Individuals without an ASD diagnosis are not usually able to access ABA but may have coverage for other behavioral treatments under private insurance and/or MassHealth.

What documentation is required by insurers?

Each insurer establishes their own criteria for evaluating medical necessity of authorization requests. This criteria may include diagnostic guidelines and information. However, the underlying diagnosis of ASD should be based on a clinician’s determination using the standardized DSM-5 criteria.

Is specific testing required?

Clinicians use a variety of tools to diagnose Autism. There are not specific tests in the DSM-5 criteria. Insurance company medical necessity criteria may reference certain tests, but shouldn’t be requiring any specific test or set of tests. Clinicians should determine what testing and diagnostic tools are necessary to assess an individual patient and determine a diagnosis.

My child received an autism diagnosis from our pediatrician. Can they access treatment?

Yes. A pediatrician who is trained or very experienced in diagnosing and working with children with Autism can provide a diagnosis. A family may still want to obtain additional testing and recommendations from specialists, but the experienced pediatrician’s diagnosis should be sufficient for insurance purposes.

Can insurers reject or challenge a diagnosis?

Insurers can request additional information or deny an authorization if there isn’t sufficient documentation. If you and your child’s providers feel that the diagnosis is sufficiently documented by adequate testing and assessment, you can appeal your insurance denial through an internal appeal, and then through an external review appeal if necessary. Note that, in addition to the specific Autism legislation and laws, there are other laws (called “parity” laws), which prevent insurers from applying excessive scrutiny or requirements for specific conditions.

What if a patient doesn’t have reports and/or there are other gaps?

Providers and families should work together to get as much information as possible. The clinicians who gave the original diagnosis may be able to provide replacement reports. School evaluations and testing may contain helpful information as well and can be submitted with authorization requests. For further information, contact an information specialist at 774-455-4056 or email us at AIRC@umassmed.edu
‍

This fact sheet and other important information is available on the AIRC website.

‍