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Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorders (ASD)
14.00.03a

Policy

COVERED (WHEN A STATE MANDATE REQUIRES COVERAGE OR A SELF-FUNDED GROUP HAS ELECTED COVERAGE)

APPLIED BEHAVIOR ANALYSIS (ABA) AND/OR OTHER RELATED STRUCTURED BEHAVIORAL PROGRAMS
The behavior methodology of ABA (e.g., discrete trial training, pivotal response training, incidental teaching), structured teaching (e.g., ​Treatment and Education of Autistic and Related Communication Handicapped Children [TEACCH]), and developmental models (e.g., Denver model, the developmental, individual-difference, relationship-based [DIR] floor-time model) used to promote learning for individuals with autism spectrum disorders (ASD) to enhance verbal and nonverbal communication, improve developmentally appropriate self-care, teach social skills, and reduce maladaptive behaviors (e.g., harm to self or others), are covered in accordance with state mandate requirements or for self-funded groups who have elected to cover ABA services for the management of ASD:

ABA for the treatment of individuals with ASD is covered when a state mandate requires coverage or a self-funded group has elected coverage and when ALL of the following criteria are met:
  • ​The individual has an established and current (within 24 months), documented diagnosis of ASD consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR) criteriausing validated autism assessment tools (e.g., Autism Diagnostic Observation Schedule (ADOS); Autism Diagnostic Interview (ADI-R); Parent Evaluation Developmental Stages (PEDS), or Brigance Diagnostic Inventory of Early Development II). 

As determined by validated developmental assessment tools, the individual cannot participate at an age-appropriate level in home, school, or community activities because of the presence of behavioral excess and/or the absence of functional skills that interfere with participation in these activities, and the target behaviors or skill deficits identified for ABA and/or other related structured behavioral interventions meet one or both of the following:

  • The target behavior or skill is 1 standard deviation (SD) or more below the mean
  • Represents a behavior that poses significant threat of harm to the individual or others

Unless a longer time frame is mandated by state law or member benefit contract, developmental assessment has been completed within the last 6 months using validated assessment tools (e.g., Vineland, Adaptive Behavior Assessment System [ABAS]). Note: Where permitted by state law or member benefit contract, developmental assessment may be completed more frequently than every 6 months as clinically indicated.


Functional behavioral assessment (FBA) using validated tools has been completed by a qualified behavior analyst certified by the Behavior Analyst Certification Board (BACB)

  • The FBA includes baseline information on the individual’s adaptive functioning within the last 6 months, or longer time frame if mandated by state law or member benefit contract.

There is an expectation on the part of the treating professional provider who has completed the initial evaluation, that the individual's behavior and skills will improve to a clinically meaningful extent, in at least two settings (home, school, community) with ABA and/or other related structured behavioral services provided by, or supervised by, a certified ABA provider.


Individualized, documented treatment plan has been developed by a licensed professional provider (e.g., MD/DO, licensed psychologist) with the following elements:

  • There are specific, quantifiable goals that relate to developmental deficits or behaviors that pose a significant risk of harm to the recipient or others.
  • Objective, observable, and quantifiable metrics are utilized to measure change toward the specific goal behaviors.
  • Documentation that adjunctive treatments (e.g., psychotherapy, social skills training, medication services, educational services) have been considered for inclusion in the treatment plan, with the rationale for exclusion.
  • The individualized treatment plan is valid for 6 months, unless there is clear evidence of regression necessitating earlier changes in the treatment plan.

Individualized, documented treatment plan is reviewed and approved every 6 months.

The individual's parent(s) and/or caregiver(s) commit to participate in the goals of the treatment plan.

The individual is medically stable and does not require 24-hour medical/nursing monitoring or procedures provided in a hospital level of care.


Continuation of Applied Behavior Analysis (ABA) and/or Other Methodologies to Promote Learning

The assessment of the individual's progress in meeting the objectives of the treatment plan shall be reviewed every 6 months unless it is determined that an earlier assessment is required. The continuation of ABA is covered for the treatment of individuals with ASD when a state mandate requires coverage and when ALL of the following criteria are met:
  • The individual shows improvement from baseline in skill deficits and problematic behaviors targeted in the approved treatment plan using validated assessments of adaptive functioning.
  • As determined by validated developmental assessment tools, the individual still cannot participate at an age-appropriate level in home, school, or community activities because of the presence of behavioral excess and/or the absence of functional skills that interfere with participation in these activities, and the target behaviors or skill deficits identified for ABA and/or other related structured behavioral interventions meet one or more of the following:
    • The target behavior or skill is 1 SD or more below the mean, or
    • Represents a behavior that poses significant threat of harm to the individual or others.
  • The individual's parent(s) and/or caregiver(s) demonstrate continued commitment to participation in the individual's treatment plan and demonstrate the ability to apply those skills in naturalized settings as documented in the clinical record.
  • The gains made toward development norms and behavior goals cannot be maintained if care is reduced.
  • Behavior issues are not exacerbated by the treatment process.
  • The individual has the required cognitive capacity to benefit from the care provided and to retain and generalize treatment gains.
  • The predicted beneficial outcome of ABA services outweighs potential harmful effects.
  • An updated diagnosis must be submitted every 24 months, or as requested by the Company, the primary care provider, psychologist, or other licensed professional provider.
Discontinuation of Applied Behavior Analysis (ABA) and/or Other Methodologies to Promote Learning

The assessment of the individual's progress in meeting the objectives of the treatment plan shall be reviewed every 6 months unless it is determined that an earlier assessment is required. The following are conditions for the discontinuation of ABA:
  • Behavioral issues are exacerbated by the treatment
  • The individual shows improvement from baseline in targeted skill deficits such that goals are achieved or maximum benefit has been reached
  • The individual does not demonstrate progress towards goals for two or more successive authorization periods
  • The individual's parent(s) and/or caregiver(s) have refused treatment recommendations
  • The individual is unlikely to continue to benefit or maintain gains from continued care
  • Continued care would be provided primarily for the convenience of the child or caregiver(s)

Transition and discharge planning from a treatment program must include a written plan that specifies details of monitoring and follow-up as is appropriate for the individual, parent(s) and/or caregiver(s). The individual's parent(s) and/or caregiver(s) and other involved professionals is consulted ongoing and prior to the planned reduction of service hours. Additional services, including behavioral therapies and other supports, is considered for the child and family as care is tapered to lower frequency.


NON-COVERED

SCHOOL, CAMP SETTINGS
Treatment of ASD that is provided at or by a school or camp, whether or not as part of an individualized education program (IEP), is a standard benefit contract exclusion for all products of the Company and is not eligible for coverage by the Company, with the following exceptions that are subject to coverage criteria and limits:
  • For certain Pennsylvania members covered under an insured employer that has 51 or more employees, treatment of ASD is covered in a school or camp setting
  • For self-funded groups that have elected such coverage, treatment of ASD in a school or camp setting​ may be covered subject to the group’s defined benefits and limitations. 
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Documentation of the performing provider's qualifications must be made available to the Company upon request.

TREATMENT PLAN DOCUMENTATION

The individual's treatment plan must document all of the following:
  • Significant history
  • Diagnosis of ASD and rationale for requiring services
  • Any related professional provider's orders
  • The goals for the services, which must be:
    • Specific and measurable
    • Individualized
    • Updated on a frequent basis
    • Based on the individual's progress
      • To improve function and/or behavior significantly
      • To prevent loss of attained skill or function and/or produce socially significant improvement in human behavior (reduce interfering behaviors)
  • Type, amount, duration, and frequency of services
  • Direct observation, measurement, and functional analysis of the relations between environment and behavior
  • Interventions such as, but not limited to, physical, occupational, speech therapy(ies), ABA and/or other related structured behavioral services that are consistent with current techniques and standards
  • Any contraindications to a course of services
  • Parent(s)' and/or caregiver(s)' awareness and understanding of the diagnoses, prognoses, and goals of services
  • When appropriate, a summary of past services and the results that were achieved
  • Reasonable expectation, based on the individual's clinical history, that withdrawal of treatment will result in the decompensation or the recurrence of signs and symptoms
  • Signature of the treating licensed professional provider (e.g., MD/DO, licensed psychologist)
DOCUMENTATION FOR DATES OF SERVICE

Treatment and modality notes for dates that services are provided and billed for must include the following documentation:
  • Date of service
  • Specific service provided
  • If modalities are utilized, documentation of the length of time spent in each modality
  • The individual's response to the service
  • Skilled, ongoing reassessment of the individual’s progress towards established goals
  • Objective, measurable, and specific documentation of progress towards goals using consistent and comparable methods
  • Changes to the treatment plan or objective reasoning for why the individual has not progressed towards goals
  • Name and credentials of the treating clinician

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, evaluation for autism spectrum disorder (ASD) is covered under the medical benefits of the Company’s products when the coverage criteria in this medical policy are met or when state mandate(s) require coverage for such services.

Individual member benefits must be verified. Some services may be subject to state mandates, coverage criteria, coverage limits, precertification or preapproval, or existing contractual exclusions.

Management of ASD may not routinely include psychiatric and/or psychological services for all individuals enrolled in a Company product. 

For self-funded groups who have elected to cover ABA services for the management of ASD, ABA services are covered subject to group’s defined benefits and limitations.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state in which the group benefit contract is issued determine the mandated coverage.

Description

AUTISM SPECTRUM DISORDER (ASD)

Autism spectrum disorder (ASD) is characterized by persistent deficits in social communication and social interactions across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing, maintaining, and understanding relationships. In addition, ASD is characterized by restricted, repetitive patterns of behavior or interests. Symptoms cause clinically significant impairment of functionality.

The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) consolidated the previously distinct autism subtypes (i.e., autistic disorder, childhood disintegrative disorder, Asperger syndrome, and pervasive developmental disorder not otherwise specified) into one unifying diagnosis of ASD. The diagnostic criteria for ASD reflect a scientific consensus of published peer-reviewed literature and clinical experience. Researchers found that these separate diagnoses were not consistently applied across different clinics and treatment centers. Individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later. It has been suggested that this criterion will encourage an earlier diagnosis of ASD. A study published by Huerta and Lord (2012) provided a comprehensive assessment of the DSM criteria for ASD based on symptom extraction from previously collected data. The study found that the criteria identified 91 percent of the children with clinical DSM-IV pervasive developmental disorder (PDD) diagnoses, suggesting that most children with the DSM-IV PDD diagnoses may retain their diagnosis of ASD based on the DSM-5 criteria. The most recent edition of DSM​ defines ASD by the presence of all of the following:
  • Persistent deficits in social communication and social interaction across multiple contexts
  • Restricted, repetitive patterns of behavior, interests, or activities
  • Symptoms must be present in the early developmental period (typically recognized in the first 2 years of life)
  • Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
Autism disorder was first described by Dr. Leo Kanner in 1943. Autism impacts the normal development of the brain in the areas of communication skills and social interaction; it is four times more common in male than female individuals. The onset of the condition usually occurs within the first 3 years of life. Individuals who are diagnosed with autism may exhibit some of the following characteristics, which can range in intensity from mild to severe, and appear in various combinations: difficulty expressing needs; a preference towards solitude; a tendency towards tantrums; difficulty with socialization; making little or no eye contact; having an inappropriate attachment to objects; an over- or under​sensitivity to pain; not recognizing danger; exhibiting strange play; and unresponsiveness to normal teaching methods and/or verbal cues. Many children with autism also have varying degrees of intellectual disability.

APPLIED BEHAVIOR ANALYSIS (ABA) AND OTHER METHODOLOGIES TO PROMOTE LEARNING
Methodologies to promote learning are believed to enhance verbal and nonverbal communication, improve developmentally appropriate self-care, teach social skills, and reduce maladaptive behaviors (e.g., harm to self or others). These methodologies are based on several model programs, including behavioral, structured teaching, and/or developmental programs.

It is generally believed that ABA is the process of applying interventions that are based on the principles of learning (e.g., positive reinforcement) derived from experimental psychology research to systematically change behavior. It can also be used to teach new skills and demonstrate that the interventions used are responsible for the observable improvements in behavior. ABA methods are reportedly used to replace maladaptive, interfering behaviors with more desirable, adaptive behaviors and to narrow the conditions under which maladaptive, interfering behaviors occur. In addition, ABA is believed to teach new skills through implicit instruction and repetition, generalize behaviors to new environments or situations, and maintain learned behaviors. For example, clear instruction with assistance (e.g., demonstration, prompting) is given to the individual, and when the individual gives a correct response, the instructor gives positive reinforcement.

Components of ABA include the following:
  • An initial assessment through observations that focus on strengths and weaknesses of the individual
  • Individualized treatment goals that are guided by the data from the initial assessment and are defined in observable terms
  • A written treatment plan or set of instructions for teaching each behavior and/or skill, developed by a professional provider
  • Training for the individual's parent(s) and/or caregiver(s) to implement the treatment plan consistently both within and outside formal treatment sessions
  • A curriculum that focuses on all of the following:
    • Breaking down skills into manageable pieces
    • Building upon skills so that an individual can learn in a natural environment
    • Teaching the individual to combine skills acquired in more complex ways
  • Documented frequent assessments of the individual's progress in measurable outcomes, using direct observational measurement methods with verification by secondary observers. As progress is made, guidance is systematically reduced.
  • No reinforcement for problem behaviors
There are many techniques used within the realm of ABA. Common techniques include, but are not limited to, the following:
  • Discrete trial training (DTT) is behaviorally based instruction that involves rewarding performances of desired behaviors and completion of tasks with tangible positive reinforcement (e.g., food, toys) paired with social praise. This therapist-directed instruction may be repeated over several days until the skill is mastered. These skills are then combined into more complex repertoires.
  • Pivotal response training is naturalistic behavioral intervention that is child-directed, and interventions are designed around materials or topics for which the individual expresses preference. Reinforcement is directly related to the task.
  • Incidental teaching is behaviorally based instruction where the interaction between adult and child occurs in the context of a natural situation where the child expresses an interest in something and the adult responds with prompts and praise.
  • Early Intensive Behavioral Intervention (EIBI) is behaviorally based instruction that uses a highly structured teaching approach to build positive behaviors (such as social communication) and reduce unwanted behaviors (such as tantrums, aggression, and self-injury). EIBI takes place in a one-on-one adult-to-child environment under the supervision of a trained professional.​ 
Competency for behavior analyst practitioners to perform services related to ABA can be demonstrated through the completion of specialized training. Organizations offer voluntary credentialing programs for behavior analyst practitioners in an effort to provide consistent credentialing. For example, the Behavior Analyst Certification Board [BACB])Inc. is a nonprofit 501(c)(3) corporation that was established in 1998 to meet professional credentialing needs identified by behavior analysts, governments, and consumers of behavior analysis services. The BACB adheres to international standards for boards and grants professional credentials. The BACB certification procedures and content undergo regular psychometric review and validation, pursuant to a job analysis survey of the profession and standards established by content experts in the field. The BACB's credentialing programs are accredited by the National Commission for Certifying Agencies (NCCA) in Washington, DC.

ABA is either provided by, or under the supervision of, a certified ABA professional provider who is either a Board-Certified Behavior Analyst-Doctoral (BCBA-D) or a Board-Certified Behavior Analyst (BCBA)-graduate-level certification in behavior analysis. A BCBA-D and BCBA are professional providers who are independent practitioners who provide behavior analytic services and supervise the work of Board- Certified Assistant Behavior Analysts, Registered Behavior Technicians, and others who provide behavior analytic interventions.

Functional behavioral assessment (FBA) is a technology grounded in the principles of ABAFBA is a process for identifying problem behaviors and developing interventions to improve or eliminate those behaviors, along with promoting more adaptive skills and behaviors. An FBA consists of information-gathering procedures that result in a hypothesis about the function(s) that the behavior is serving for the individual. The process also results in the identification of environmental antecedents and consequences that are maintaining the behavior. The information gathered is used to develop an effective and efficient treatment plan. Applied behavior analysis systematically applies behavioral intervention techniques coupled with a functional assessment of environmental factors to determine the relationship between the individual and their environment, to develop, maintain, or restore the functioning of individuals with ASD.

Some methodologies to promote learning have also emerged, and although they are not considered behavioral, they share common elements with behavioral methodologies. For example, the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) model of structured teaching uses many forms of visual supports, such as picture schedules, to assist individuals with ASD. Another modality commonly used with individuals who have ASD is the developmental approach. Examples of the developmental approach include, but are not limited to, the Denver model (which focuses on intensive teaching and developing social communicative skills) and/or the developmental, individual-difference, relationship-based (DIR) floor-time model (which focuses on building emotional reciprocity). Despite the common use of such methodologies to promote learning, most have not been empirically validated.

Among the many methodologies available for the management of ASD, ABA is arguably the most studied treatment modality in the field. Most evidence-based treatment models are based on principles of ABA (AAP Clinical Report 2020). ​ABA methodology requires the collection and analysis of detailed data about the child's response to therapy. When performed in the manner in which it was developed, ABA includes intensive data collection, which provides monitoring of efficacy of individual treatment programs and promotes change in programs and goals when needed. ABA methodologies may assist in the management of conditions associated with ASD. ​There is growing evidence from observational studies and systematic reviews and a general consensus in the professional community that ABA can be associated with positive outcomes for children with ASD. The AAP Clinical Report (2020) states that evidence supports the use of behavioral interventions (e.g., ABA) for skill-building. However, despite these improvements in the quality of the included literature, a need remains for studies of interventions across settings and continued improvements in methodologic rigor. Furthermore, given the heterogeneity of the ASD phenotype, the behavioral/learning needs of children, youth, and adults need to be individualized by using available clinical data (AAP Clinical Report 2020).​​ 

EDUCATIONAL SERVICES
Forming a therapeutic alliance of the parent(s) and/or caregiver(s), family members, and the school staff is the most crucial part of the treatment plan for children who are diagnosed with ASD. The treatment plan should include a realistic assessment of the available resources for the child. Educational services, including special education and some forms of behavior modification, are the central and essential aspects of treatment. Federal law 94-142, originally called the Education of All Handicapped Children Act (now known as the Individuals with Disabilities Education Act [IDEA]), mandates early intervention with appropriate developmental, therapeutic, and family support services for a child younger than 3 years of age with a known developmental disability or who demonstrates a developmental delay. When a child turns 3 years old, services shift so that school districts provide an appropriate plan of educational services (individualized educational plan [IEP]) for affected children. Education of family members and caregivers is essential in the management of ASD. Parents and/or caregivers should understand the child's developmental needs and develop practical strategies to meet their educational and social goals.

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Maglione MA, Gans D, Das L, et al. Nonmedical interventions for recipient with ASD: recommended guidelines and further research needs. Pediatrics. 2012;130(2):169-178.

Malik S. Role of applied behavior analysis in behavior modification of autistic recipient. Int J Med Appl Health. 2013;1(2):52-59.


Matson JL, Benavidez D A, Compton L S, et al. Behavior treatment of autistic persons: A review of research from 1980 to the present. Res Dev Disabil.1996;17(6):433-465.

McEachin JJ, Smith T, Lovaas OI. Long-term outcome for recipient with autism who received early intensive behavior treatment. Am J Ment Retard.1993;97(4):359-372.

Mohammadzaheri F, Koegel L, Rezaee M, et al. Randomized clinical trial comparison between pivotal response treatment (PRT) and structured applied behavior analysis (ABA) intervention for recipient with autism. J Autism Dev Disord. 2014;44(11):2769-2777.


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Coding

CPT Procedure Code Number(s)
0362T, 0373T, 97151, 97153, 97154, 97155, 97156, 97157, 97158​

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
F84.0 Autistic disorder

F84.2 Rett's syndrome

F84.3 Other childhood disintegrative disorder

F84.5 Asperger's syndrome

F84.8 Other pervasive developmental disorders

F84.9 Pervasive developmental disorder, unspecified​


HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)

N/A


​Modifiers

AF Specialty Physician

AH Clinical Psychologist

AJ Clinical Social Worker

HM Less than Bachelor's Degree level

HN Bachelor's Degree level

HO Master'​s Degree level

HP Doctoral Level

TD RN​

Coding and Billing Requirements


Policy History

1/1/2024
1/2/2024
14.00.03
Medical Policy Bulletin
Commercial
No