Digital Health Technologies for Attention Deficit/Hyperactivity Disorder

POLICY NUMBER

A.3.03.03

DESCRIPTION

Digital health technologies is a broad term that includes categories such as mobile health, health information technology, wearable devices, telehealth and telemedicine, and personalized medicine. These technologies span a wide range of uses, from applications in general wellness to applications as a medical device, and include technologies intended for use as a medical product, in a medical product, as companion diagnostics, or as an adjunct to other medical products (devices, drugs, and biologics). The scope of this policy includes only those digital technologies that are intended to be used for therapeutic application and meet the following 3 criteria: 1) Must meet the definition of "Software as a medical device" which states that software is intended to be used for a medical purpose, without being part of a hardware medical device or software that stores or transmits medical information. 2) Must have received marketing clearance or approval by the U.S. Food and Drug Administration (FDA) either through the de novo premarket process or 510(k) process or pre-market approval and 3) Must be prescribed by a healthcare provider. This policy will assess whether a digital therapy in the form of a computer game can improve attention in children with ADHD.

Scope of Policy

Software has become an important part of product development and is integrated widely into digital platforms that serve both medical and non-medical purposes. The 3 broad categories of software use in medical devices are:

1. Software used in the manufacture or maintenance of a medical device (eg, software that monitors x-ray tube performance to anticipate the need for replacement),

2. Software that is integral to a medical device or software in a medical device (eg, software used to "drive or control" the motors and the pumping of medication in an infusion pump),

3. Software, which on its own is a medical device referred to as "Software as a Medical Device" (SaMD) (eg, software that can track the size of a mole over time and determine the risk of melanoma).

The International Medical Device Regulators Forum, a consortium of medical device regulators from around the world led by the U.S. Food and Drug Administration (FDA) defines SaMD as "software that is intended to be used for one or more medical purposes that perform those purposes without being part of a hardware medical device". Such software was previously referred to by industry, international regulators, and health care providers as "standalone software," "medical device software," and/or "health software," and can sometimes be confused with other types of software.

The scope of this policy includes only those digital technologies that are intended to be used for therapeutic application and meet the following 3 criteria:

1. Must meet the definition of "Software as a medical device" (SaMD) which states that software is intended to be used for a medical purpose, without being part of a hardware medical device or software that stores or transmits medical information.

2. Must have received marketing clearance or approval by the U.S. FDA either through the de novo premarket process or 510(k) process or pre-market approval and,

3. Must be prescribed by a healthcare provider.

BCBSA Evaluation Framework for Digital Health Technologies

SaMDs, as defined by the FDA, are subject to the same evaluation standards as other devices. The Blue Cross and Blue Shield Association Technology Evaluation Criterion are as follows:

1. The technology must have final approval from the appropriate governmental regulatory bodies.

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.

3. The technology must improve the net health outcome.^a

4. The technology must be as beneficial as any established alternatives.

5. The improvement must be attainable outside the investigational settings.^b

^a The technology must assure protection of sensitive patient health information as per the requirements of The Health Insurance Portability and Accountability Act of 1996 (HIPAA).^b The technology must demonstrate usability in a real-world setting.

Other regulatory authorities such as the United Kingdom's National Institute for Health and Care Excellence (NICE) have proposed standards to evaluate SaMD.

In April 2020, EndeavorRx (Akili Interactive Labs) received marketing clearance by the U.S. Food and Drug Administration (FDA) through the De Novo premarket review process (DEN200026). EndeavorRx is a prescription device that is indicated to “improve attention function as measured by computer-based testing in children ages 8-12 years old with primarily inattentive or combined type ADHD, who have a demonstrated attention issue. Patients who engage with EndeavorRx demonstrate improvements in a digitally assessed measure Test of Variables of Attention (TOVA) of sustained and selective attention and may not display benefits in typical behavioral symptoms, such as hyperactivity.” EndeavorRx is intended to be used as part of a therapeutic program that may include clinician-directed therapy, medication, and/or educational programs.

POLICY

The use of EndeavorRx is considered investigational for all indications including attention-deficit/hyperactivity disorder.

POLICY EXCEPTIONS

Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

05/15/2022: New policy added. Approved by the Medical Policy Advisory Committee.

09/30/2022: Code Reference section updated to revise HCPCS code A9291, effective 10/01/2022.

12/20/2022: Code Reference section updated to add new CPT code 98978, effective 01/01/2023.

08/24/2023: Policy description extensively revised regarding digital health technologies. Policy statement revised to state that the use of EndeavorRx is considered investigational for all indications including attention-deficit/hyperactivity disorder. It previously stated: Prescription digital therapy is considered investigational for the treatment of attention-deficit/hyperactivity disorder.

08/15/2024: Policy title updated to change "Digital Health Therapies" to "Digital Health Technologies." Policy reviewed. Policy statement unchanged.

12/20/2024: Code Reference section updated to revise description for CPT code 98978 and to add new HCPCS codes G0552, G0553, and G0554 effective 01/01/2025.

SOURCE(S)

Blue Cross Blue Shield Association policy # 3.03.03

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

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