                                 CODE OF VIRGINIA

COVERAGE FOR PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISORDERS ASSOCIATED WITH
STREPTOCOCCAL INFECTIONS AND PEDIATRIC ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME (§
38.2-3418.22)

A. As used in this section:
			&#8220;Pediatric acute-onset neuropsychiatric syndrome&#8221; or
&#8220;PANS&#8221; means a clinically defined disorder characterized by the
sudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions,
concomitant with acute behavioral deterioration in at least two designated
domains. Comorbid PANS symptoms may include anxiety, sensory amplification or
motor abnormalities, behavioral regression, deterioration in school performance,
mood disorder, urinary symptoms, or sleep disturbances. PANS does not require a
known trigger, although it is believed to be triggered by one or more pathogens.
			&#8220;Pediatric autoimmune neuropsychiatric disorders associated with
streptococcal infections&#8221; or &#8220;PANDAS&#8221; means a subset of PANS
that has five distinct criteria for diagnosis, including (i) abrupt
&#8220;overnight&#8221; OCD or dramatic, disabling tics; (ii) a
relapsing-remitting, episodic symptom course; (iii) young age at onset; (iv)
presence of neurologic abnormalities; and (v) temporal association between
symptom onset and Group A streptococcal infection. The five criteria of PANDAS
are usually accompanied by similar comorbid symptoms as found in PANS.

B. Notwithstanding the provisions of &#xA7; 38.2-3419 or subdivision A 1 of
&#xA7; 38.2-6506, each insurer proposing to issue individual or group accident
and sickness insurance policies providing hospital, medical and surgical, or
major medical coverage on an expense-incurred basis; each corporation providing
individual or group accident and sickness subscription contracts; and each
health maintenance organization providing a health care plan for health care
services shall provide coverage for the prophylaxis, diagnosis, and treatment of
pediatric autoimmune neuropsychiatric disorders associated with streptococcal
infections and pediatric acute-onset neuropsychiatric syndrome. Such coverage
shall include coverage for treatment using antimicrobials, medication, and
behavioral therapies to manage neuropsychiatric symptoms, immunomodulating
medicines, plasma exchange, and intravenous immunoglobulin therapy.

C. No insurer, corporation, or organization providing coverage pursuant to this
section shall (i) deny or delay the coverage required by this section because
the enrollee previously received treatment, including the same or similar
treatment, for these conditions or because the enrollee was diagnosed with or
received treatment for his condition under a different diagnostic name,
including autoimmune encephalopathy; (ii) limit coverage of immunomodulating
therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome
and pediatric autoimmune neuropsychiatric disorders associated with
streptococcal infections in a manner that is inconsistent with the treatment
guidelines developed by a consortium convened for the purposes of researching,
identifying, and publishing best practice standards for diagnosis and treatment
of such syndrome or disorders that are accessible for medical professionals and
are based on evidence of positive patient outcomes; (iii) require a trial of
therapies that treat only neuropsychiatric symptoms before authorizing coverage
of immunomodulating therapies for the treatment of pediatric acute-onset
neuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections; or (iv) deny coverage for out-of-state
treatment if the service is not available within the Commonwealth.

D. Nothing in this section shall prevent an insurer, corporation, or
organization from requesting treatment notes and the anticipated duration of
treatment and outcomes.

E. Nothing shall preclude the undertaking of usual and customary procedures,
including prior authorization, to determine the appropriateness of, and medical
necessity for, treatment of PANDAS and PANS under this section, provided that
all such appropriateness and medical necessity determinations are made in the
same manner as those determinations are made for the treatment of any other
illness, condition, or disorder covered by such policy, contract, or plan.

F. The coverage provided under this section shall not be more restrictive than
or separate from coverage provided for any other illness, condition, or disorder
for purposes of determining deductibles, benefit year or lifetime durational
limits, benefit year or lifetime dollar limits, lifetime episodes or treatment
limits, copayment and coinsurance factors, and benefit year maximum for
deductibles and copayments and coinsurance factors.

G. The requirements of this section shall apply to all insurance policies,
contracts, and plans delivered, issued for delivery, reissued, or extended in
the Commonwealth on and after January 1, 2026, or at any time thereafter when
any term of the policy, contract, or plan is changed or any premium adjustment
is made.

H. This section shall not apply to short-term travel, accident-only, or limited
or specified disease policies or contracts, nor to policies or contracts
designed for issuance to persons eligible for coverage under Title XVIII of the
Social Security Act, known as Medicare, or any other similar coverage under
federal governmental plans.

HISTORY: 2025, c. 8.