MEDICAL POLICY – 3.01.

510
Applied Behavior Analysis (ABA)
Effective Date: Nov. 1, 2018 RELATED MEDICAL POLICIES:
Last Revised: Oct. 26, 2018 None
Replaces: N/A

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POLICY CRITERIA | CODING | RELATED INFORMATION

EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Applied behavior analysis (ABA) applies the principles of how people learn and their motivations
to change behavior. The idea behind ABA is that behaviors that are rewarded will increase and
behaviors that are not rewarded will decrease and eventually stop. There are several different
ABA techniques. Generally, each focuses on what happens before a behavior occurs and what
happens after. ABA has been used for people with autism to try to increase language and
communication, enhance attention and focus, and help with social skills and memory. This policy
describes when ABA may be considered medically necessary. It also discusses the providers the
plan covers for ABA services, and the usual number of hours covered during ABA evaluation and
therapy.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a
service may be covered.

Policy Coverage Criteria

Service Medical Necessity
Psychotherapy sessions Psychotherapy sessions that include applied behavior analysis
interventions, that are offered separately from a
comprehensive, intensive program using a program manager
and therapists and/or therapy assistants, may be considered
medically necessary for the treatment of covered mental
disorders when:
 Provided by state-licensed clinicians practicing within the legal
scope of their licensure
AND
 The services are consistent with psychotherapy sessions
designated by current CPT terminology.
Applied Behavior Analysis Treatment that consists of Applied Behavior Analysis (ABA)
(ABA) provided several hours daily on treatment days and utilizing a
program manager, lead therapist, or supervising clinician plus
therapists or therapy assistants may be considered medically
necessary when the following criteria are met:
 The member has been diagnosed with Autism Spectrum
Disorder (DSM-5 299.00; ICD-9 299.0, 299.00, 299.01, 299.1,
299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91;
DSM-IV 299.00, 299.10, or 299.80; ICD-10 F84, F84.0, F84.2,
F84.3, F84.5, F84.8, or F84.9) by a psychiatrist, psychologist,
neurologist, or developmental pediatrician. The diagnosis has
been validated by a documented comprehensive assessment
demonstrating the presence of DSM-5 diagnostic criteria if the
diagnosis was made after the release of DSM-5, or
demonstrating the presence of DSM-IV diagnostic criteria if the
diagnosis was made prior to the release of DSM-5. ABA is
considered to be not medically necessary for any other
conditions.
 The Autism Spectrum Disorder (ASD) is adversely impacting the
member’s development, communication, social interactions, or
behavior such that the member is unable to adequately
participate in age-appropriate home, school, or community
activities, or the member is a safety risk to self, others, or
property.
 The services provided are Comprehensive ABA or Focused ABA
as described by the Behavior Analyst Certification Board.

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Service Medical Necessity
Comprehensive ABA, such as Early Intensive Behavioral
Intervention, addresses multiple domains simultaneously with
the goal of bringing functioning to or near levels typical for
chronological age. Focused ABA has a goal of addressing a
limited number of behavioral or skill development targets.
 An individualized treatment plan is developed and documented
prior to or within 30 days of beginning ABA. The treatment plan
is based on a comprehensive assessment, often called a
functional analysis or Functional Behavioral Analysis that was
conducted prior to, but no earlier than within 6 months of, the
initiation of ABA. The treatment plan includes the following
elements:
o Verification of ASD diagnosis by DSM-5 or DSM-IV criteria.
o Identification and detailed description of targeted
symptoms and behaviors. Targeted symptoms and
behaviors must be those which are preventing the member
from adequately participating in age-appropriate home,
school, or community activities, or that are presenting a
safety risk to self, others, or property.
o Objective baseline measurements of each targeted
symptom and behavior via measurements that are
administered by or approved by the program manager/lead
behavioral therapist (defined below).
o Detailed description of treatment modality or modalities
and interventions for each targeted symptom and behavior.
o Treatment goals and measures of progress for each
targeted symptom and behavior, with estimated
timeframes for achieving the goals.
o Inclusion of parents (or active caretakers or legal guardians
when appropriate); specifically, detailed description of
interventions with parents, including as appropriate
parental education, training, coaching, support, overall
goals for parents, and plan for transferring interventions
with member/identified patient to parents.
o Plan for communication and coordination with other
providers and agencies as appropriate, including day care,
school, and other health care providers.

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Service Medical Necessity
o Total number of days per week and hours per day of direct
services to the member/identified patient and of services to
parents. Total number of hours per week of supervision of
therapy assistants. Total number of hours per month of
program development, treatment plan development, and
case review.
o Measurable criteria for completing treatment, with
projected plan for continued care after discharge from ABA.
 Evaluation of progress:
o Data on targeted symptoms and behaviors is collected by
direct therapy providers during each ABA session. The
program manager/lead behavioral therapist collates and
evaluates the data from all sessions at least once/week, and
summarizes progress on each targeted symptom and
behavior at least once every six months.
 Progress is assessed and documented for each targeted
symptom and behavior, including progress towards the
defined goals, and including the same modes of
measurement that were utilized for baseline
measurements of specific symptoms and behaviors.
 When goals have been achieved, either new goals
should be identified that are based on targeted
symptoms and behaviors which are preventing the
member from adequately participating in age-
appropriate home, school, or community activities, or
that are presenting a safety risk to self, others, or
property; or, the treatment plan should be revised to
include a transition to less intensive interventions.
 When there has been inadequate progress re: targeted
symptoms and behaviors, or no demonstrable progress
within a six month period, or specific goals have not
been achieved within the estimated timeframes, there
should be an assessment of the reasons for inadequate
progress or not meeting the goals, and treatment
interventions should be modified or changed in order
to attempt to achieve adequate progress, or a change in
providers should take place, whichever is appropriate.

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Service Medical Necessity
 When there is continued absence of adequate
improvement or when progress plateaus, and there is
no reasonable expectation of further progress, the
treatment plan should be revised to reflect a planned
discontinuation of ABA, and referral to other resources
as appropriate, allowing for a brief period of time for
termination with the member and parents.

Please see below for information on ABA service providers.

Applied Behavior Analysis (ABA) Service Providers

Applied Behavior Analysis (ABA) services are either provided by, or are under the
supervision of, a clinician (often referred to as the program manager or lead behavioral
therapist) who is one of the following:
 A Board Certified Behavior Analyst (BCBA), certified by the Behavior Analyst Certification Board,
and state-licensed or state-certified in states that require state licensure or state certification
for behavior analysts.
 Any other state-licensed Behavior Analyst.
 A state-licensed physician who is a psychiatrist, developmental pediatrician, or pediatric
neurologist.
 A state-licensed psychiatric advanced nurse practitioner/advanced registered nurse
practitioner.
 A state-licensed psychologist.
 A state-licensed Master’s level mental health clinician (eg, licensed clinical social worker,
licensed marriage and family counselor, licensed mental health counselor).
 A state-licensed occupational therapist or speech therapist.
 Any other provider whose legally-permitted scope of licensure includes behavior analysis

Alternately, in Washington State, ABA services may be provided by an agency that is

licensed by the Department of Social and Health Services, Division of Behavioral Health
Resources as a Community Mental Health Agency or as a Licensed Behavioral Health
Agency, and is also certified by the Department of Social and Health Services, Division of
Behavioral Health Resources to deliver ABA services. The agency must meet all requirements
of, and must deliver ABA services in full compliance with, WAC 388-865-0469. In other
states that specifically license agencies for ABA, ABA services may be provided by an agency
that is so licensed.

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Applied Behavior Analysis (ABA) Service Providers

When direct services to the member/identified patient and parents are provided by
individuals who are not BCBAs or one of the licensed health care professionals listed above
(often referred to as therapy assistants, behavioral technicians, or paraprofessionals), the
therapy assistants/behavioral technicians/paraprofessionals receive weekly clinical
supervision from the program manager/lead behavioral therapist as follows for each
patient: generally two hours for every 10 hours of direct service provision, with a minimum
of two hours weekly when direct service provision is 10 hours per week or less. Supervision
may need to be temporarily increased to meet individual patient needs at certain times in
treatment, eg, a significant change in response to treatment, or a significant increase in
clinical complexity. Supervision may be conducted entirely in-person, or may be a
combination of in-person and remote supervision, but some portion of the supervision (no
specific time amount is specified) should be conducted in-person. Some supervisory time
(no specific time amount is specified) should be utilized for direct observation of direct
service provision by the therapy assistants/behavioral technicians/paraprofessionals. In
addition, the program manager/lead behavioral therapist conducts a case review and
treatment plan review with the therapy assistants/behavioral technicians/paraprofessionals
at least once/month. Although some states are licensing therapy assistants/behavioral
technicians, these requirements apply to all therapy assistants/behavioral
technicians/paraprofessionals regardless of licensure status.

Therapy assistants, behavioral technicians, or paraprofessionals must be state registered,

certified, or licensed in states that require state registration, certification, or licensure for
those practitioners.

Board Certified assistant Behavior Analysts (BCaBAs) or state-licensed Assistant Behavior

Analysts may function as program managers/lead behavioral therapists only in states in
which state law or regulation stipulates that such functioning is in the legally-permitted
scope of practice of BCaBAs or licensed assistant behavior analysts. Board Certified assistant
Behavior Analysts or state-licensed Assistant Behavior Analysts may not provide ABA
treatment services without supervision by a Board Certified Behavior Analyst, Licensed
Behavior Analyst, or other higher-level licensed provider as permitted under state law or
regulation.

Direct treatment services provided by Board Certified assistant Behavior Analysts and state-
licensed Assistant Behavior Analysts are considered to be equivalent to services provided by
therapy assistants/behavioral technicians/paraprofessionals.

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Applied Behavior Analysis (ABA) Service Providers

Supervision of ABA programs and of clinicians providing direct treatment services must be
provided by licensed behavior analysts in states in which state law or regulation stipulates
that only licensed behavior analysts are permitted to provide ABA supervision, or by
licensed behavior analysts or licensed assistant behavior analysts in states in which state law
or regulation stipulates that only licensed behavior analysts or licensed assistant behavior
analysts are permitted to provide ABA supervision (see next paragraph).

Licensed assistant behavior analysts may function as program managers/lead behavioral

therapists and provide supervision to therapy assistants, behavioral technicians, or
paraprofessionals who are providing direct treatment services, in states in which state law or
regulation stipulates that supervision of therapy assistants, behavioral technicians, or
paraprofessionals is in the legally-permitted scope of practice of licensed assistant behavior
analysts. When a licensed assistant behavior analyst provides supervision to therapy
assistants, behavioral technicians, or paraprofessionals, then supervision of the licensed
assistant behavior analyst by a licensed behavior analyst, a BCBA, or other licensed clinician,
although required, is considered to be a component of the licensed assistant behavior
analyst‘s training and therefore not a medically necessary component of the treatment
program.

Board Certified assistant Behavior Analysts must be state certified or licensed in states that
require certification or licensure for BCaBAs.

After diagnosis and referral for ABA, 6-10 hours is usually sufficient for the initial
evaluation/assessment for ABA and initial treatment planning by a program manager/lead
behavioral therapist if focused ABA is planned. However, for Comprehensive ABA, more
complex cases, or cases in which a complete functional analysis is needed, may require up to
15-20 hours for the initial assessment and treatment planning. The assessment may include
time-limited observation in the school setting when behavioral or other difficulties that are
manifestations of the individual’s Autism Spectrum Disorder are evident and problematic in
the school setting. Following the initial evaluation/assessment, 20-40 hours total per week is
the usual range of services for Comprehensive ABA, including direct services to
member/identified patient and/or parents by program manager/lead behavioral therapist
and/or therapy assistants/behavioral technicians/paraprofessionals, program development,
treatment plan development, case review, and supervision. Fewer hours are required for
Focused ABA. There is no evidence in the published literature to support more than 40 hours
per week under any circumstances. Direct services to the member/identified patient are

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Applied Behavior Analysis (ABA) Service Providers
generally provided one-on-one or with parents present, most often in the home setting but
also in community settings depending on the member/identified patient’s needs and the
settings where significant difficulties occur. Social skills groups may be appropriate as a
component of a member’s overall ABA program.

Functional analysis re-assessments, when determined to be appropriate, are generally

conducted once every 6 to 12 months. The re-assessments may include time-limited
observation in the school setting when behavioral or other difficulties that are
manifestations of the individual’s Autism Spectrum Disorder continue to be evident and
problematic in the school setting.

Coding

Code Description
CPT
0359T Behavior identification assessment – Used for initial evaluation/assessment, initial
functional analysis, and periodic functional analysis re-assessments (must be done by a
program manager/lead behavioral therapist) (code terminated 1/1/19)

Alternate to HCPCS H0031

0362T Behavior identification supporting assessment, each 15 minutes of technicians' time

face-to-face with a patient, requiring the following components: administration by the
physician or other qualified health care professional who is on site; with the assistance
of two or more technicians; for a patient who exhibits destructive behavior; completion
in an environment that is customized to the patient's behavior

Alternate to HCPCS H2014

0363T Exposure behavior follow-up assessment, administered by physician or other qualified

health care professional with the assistance of one or more technicians, face-to-face
with the patient; each additional 30 minutes of technician(s) time (code terminated
1/1/19)

Alternate to HCPCS H2014

0364T Adaptive behavior treatment by protocol, administered by technician, face-to-face

with one patient; first 30 minutes of technician time (code terminated 1/1/19)

Alternate to HCPCS H2014

0365T Adaptive behavior treatment by protocol, administered by technician, face-to-face

with one patient; each additional 30 minutes of technician time (List separately in

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Code Description
addition to code for primary procedure) (code terminated 1/1/19)

Alternate to HCPCS H2014

0368T Adaptive behavior treatment with protocol modification administered by physician or

other qualified health care professional with one patient; first 30 minutes of patient
face-to-face time (code terminated 1/1/19)

Alternate to HCPCS H2019

0369T Adaptive behavior treatment with protocol modification administered by physician or

other qualified health care professional with one patient; each additional 30 minutes of
patient face-to-face time (List separately in addition to code for primary procedure)
(code terminated 1/1/19)

Alternate to HCPCS H2019

0370T Family adaptive behavior treatment guidance, administered by physician or other

qualified health care professional (without the patient present) (code terminated
1/1/19)

Alternate to HCPCS H2019

0372T Adaptive behavior treatment social skills group, administered by physician or other
qualified health care professional face-to-face with multiple patients (code terminated
1/1/19)

Alternate to HCPCS H2019

HCPCS
H0031 Mental health assessment – Used for initial evaluation/assessment, initial functional
analysis, and periodic functional analysis re-assessments (must be done by a program
manager/lead behavioral therapist)

H0032 Mental health service plan development – Used for program development, treatment
plan development or revision, data analysis, case review, treatment team conferences,
supervision of therapy assistants/paraprofessionals, and for real-time direct
communication/coordination with other providers (must be done by a program
manager/lead behavioral therapist)

H2014 Skills training and development, per 15 minutes – Used for direct services to member
and/or parents (including parent education and training) by therapy
assistants/behavioral technicians/paraprofessionals

H2019 Therapeutic behavioral services, per 15 minutes – Used for direct services to member
and/or parents (including parent education and training) by program managers/lead
behavioral therapists

S5108 Home care training to home care client – Used for direct services to member by
therapy assistants/behavioral technicians/paraprofessionals

S5109 Home care training to home care client – Used for direct services to member by

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Code Description
therapy assistants/behavioral technicians/paraprofessionals

S5110 Home care training ,family -- Used for direct services to parents and/or family
(including parent education and training) by therapy assistants/behavioral
technicians/paraprofessionals

S5111 Home care training ,family -- Used for direct services to parents and/or family
(including parent education and training) by therapy assistants/behavioral
technicians/paraprofessionals

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS
codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Related Information

Benefit Application

Except when otherwise directed by specific health plan stipulations (ie, member contracts or
summary plan descriptions), covered providers for ABA for Autism Spectrum Disorders are those
which are indicated within the Applied Behavior Analysis (ABA) Service Providers section
above. Services provided by unlicensed individuals, including therapy assistants/behavioral
technicians/paraprofessionals and BCBAs that are not state-licensed, are covered only for the
provision of ABA for Autism Spectrum Disorders.

Except when otherwise directed by specific health plan stipulations (ie, member contracts or
summary plan descriptions), covered services for ABA for Autism Spectrum Disorders are those
which are listed in the Coding section above.

Except when otherwise directed by specific health plans, in-network providers of ABA for Autism
Spectrum Disorders must use the codes listed in the Coding section above in order to be
reimbursed for ABA services.

Group treatment is covered only for social skills groups, and only when conducted by program
managers/lead behavioral therapists, not when conducted by therapy assistants/behavioral
technicians/paraprofessionals. Group treatment other than social skills groups is considered to
be not medically necessary because there is no credible scientific evidence that group treatment
other than social skills therapy is an effective component of ABA for the treatment of ASD.

Social skills groups in excess of two sessions per day are considered to be not medically
necessary. All credible studies demonstrating the effectiveness of ABA have been conducted

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with ABA consisting predominantly of individual and family treatment with minimal group
treatment, at most one to two social skills group sessions per week.

Individual treatment when the member is in a group setting, as distinct from group treatment, is
covered only when the clinician is working exclusively with the member for the entire time that
the member is in the group setting.

Except when otherwise directed by specific health plan stipulations, program development,
treatment plan development and revision, data analysis, case review, supervision of therapy
assistants/behavioral technicians/paraprofessionals, and real-time direct
communication/coordination with other providers are covered services as part of the provision
of ABA for Autism Spectrum Disorders. Program development, treatment plan development and
revision, data analysis, case review, supervision of therapy assistants/behavioral
technicians/paraprofessionals, and real-time direct communication/coordination with other
providers are covered only for program managers/lead behavioral therapists, not for therapy
assistants/behavioral technicians/paraprofessionals.

Team meetings are covered only (1) when they are specifically for treatment plan development
or revision or case review for one specific patient, or (2) when meeting with the parents of one
specific patient to discuss the treatment of that patient.

Charting data or plotting graphs, as distinct from actual analysis of data, are not covered.

Therapy assistants’/behavioral technicians’/paraprofessionals’ time in supervision is not a

covered service because the service being provided (supervision) is being delivered by the
program manager/lead behavioral therapist, not by the therapy assistant(s)/behavioral
technician(s)/paraprofessional(s). Exception: When the program manager/lead behavioral
therapist is supervising the therapy assistant/behavioral technician/paraprofessional while the
latter is providing covered direct treatment services, then for only the time during which that is
taking place, both the supervision by the program manager/lead behavioral therapist and the
direct treatment services by the therapy assistant/behavioral technician/paraprofessional are
covered services.

Except when otherwise directed by specific health plans, services not listed in the Coding
section above are not covered services for ABA for Autism Spectrum Disorders.

Some portion of the direct service provision (no specific time amount is specified) may take
place in the school setting when behavioral or other difficulties that are manifestations of the
individual’s Autism Spectrum Disorder are evident and problematic in the school setting. Direct
service provision in the school setting must consist entirely of bona-fide ABA treatment
activities; the ABA clinician may not be utilized as a classroom aide for the patient, as a 1:1

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teacher for the patient, or in any other capacity that is a function of and the responsibility of the
school system.

Schools and school programs for individuals with Autism Spectrum Disorder, and tuition for
specialized schools for individuals with Autism Spectrum Disorder, are non-covered activities
and services because schools are not covered facility types, and educational therapy,
educational services, and services that are the responsibility of school districts, and should
therefore be provided by school staff, are specifically excluded from coverage (except if
otherwise directed by specific health plan stipulations). Although such schools or programs may
claim that they consist of ABA services, significant portions of the school day or programs are
for educational and other activities that are not ABA services. Coverage is allowed for direct
service provision in the school setting that consists entirely of bona-fide ABA treatment
activities, delivered by covered ABA providers.

Camps, camp programs, day camps, school break camps, summer camps, and any similar
activities are non-covered activities because camping, camp programs, recreational programs,
and recreational programs are specifically excluded from coverage (except if otherwise directed
by specific health plan stipulations). Although such programs may claim that they consist of ABA
services, significant portions of the programs are for recreational purposes (not covered), and
are for the purpose of providing professional assistance so that youngsters with ASD can
partake of normal recreational camp activities, which does not constitute the provision of
treatment. In addition, the goals and interventions in these programs are not a continuation of
the same goals and interventions that were in place prior to the camp programs, do not
continue as part of the patients’ ABA treatment after the camp programs, and generally do not
target specific individualized impairments that were being targeted for treatment prior to the
camp programs and that will continue to be being targeted for treatment after the camp
programs, ie, the goals, interventions, and targeted impairments are not components of
patients’ ongoing ABA treatment plans and services. Also, although 1:1 direct treatment services
constitute the core component of and the majority of time for ABA, these program provide little
or no direct treatment services.

Direct service provision by telehealth modalities, including to parents or family members, is

considered to be not medically necessary because there is no credible scientific evidence that
the provision of ABA by telehealth modalities is effective or safe. All credible studies
demonstrating that ABA is effective and safe have been conducted with in-person evaluations
and intensive in-person direct treatment services.

The following are considered to be unnecessary duplication of services and therefore not
medically necessary in the provision of ABA services:

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 More than one program manager/lead behavioral therapist for a member/identified patient
at any one time.

 More than one provider group/clinic/agency/organization providing ABA services for a

member/identified patient at any one time.

 More than one clinician (program managers/lead behavioral therapists, or therapy

assistants/behavioral technicians/paraprofessionals, or program manager/lead behavioral
therapist and therapy assistant/behavioral technician/paraprofessional) providing direct
(ABA) treatment services to the same identified patient at the same time.

The provision of ABA treatment and a different type of treatment (eg, ABA and speech therapy)
to the same identified patient at the same time is considered to be not medically necessary.
Individuals with ASD cannot adequately focus on and engage in two different treatment
modalities simultaneously.

With the exception of social skills groups, the provision of ABA direct treatment services to more
than one identified patient in the same treatment session is considered to be not medically
necessary. There is no established clinical need for or advantage to more than one patient in a
treatment session other than social skills groups. (This does not apply to family therapy, or to
collateral sessions with a parent or parents, in which or for which there is only one identified
patient.) However, this does apply to treating siblings with the exception of bona-fide family
therapy sessions or social skills groups (the latter are expected to include other patients, not just
siblings), the provision of ABA direct treatment services to siblings together is considered to be
not medically necessary.

Activities and therapy modalities that do not constitute behavioral assessments and
interventions utilizing applied behavior analysis techniques are considered to not constitute ABA
services, and are therefore either non-covered services if listed as member contract exclusions,
or are otherwise considered to be not medically necessary. Examples include (but are not limited
to):

 Training of therapy assistants/behavioral technicians/paraprofessionals (as distinct from

supervision)

 Preparation work prior to the provision of services

 Accompanying the member/identified patient to appointments or activities outside of the

home (eg, recreational activities, eating out, shopping, play activities, medical appointments),
except when the member/identified patient has demonstrated a pattern of significant
behavioral difficulties during specific activities, , in which case the clinician is present to

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 actively provide treatment, not to just supervise, control, or contain the member/identified
patient

 Transporting the member/identified patient in lieu of parental/other family member

transport, except when the member/identified patient has demonstrated a pattern of
significant behavioral difficulties during transport, in which case transport is still provided by
parent/other family member, and the clinician is present to actively provide treatment to the
member/identified patient during transport, not to just supervise, control, or contain the
member/identified patient

 Assisting the member with academic work or functioning as a tutor, except when the
member has demonstrated a pattern of significant behavioral difficulties during school work

 Functioning as an educational or other aide for the member/identified patient in school

 Provision of services that are part of an IEP and therefore should be provided by school
personnel, or other services that schools are obligated to provide

 Provider doing house work or chores, or assisting the member/identified patient with house
work or chores, except when the member has demonstrated a pattern of significant
behavioral difficulties during specific house work or chores, or acquiring the skills to do
specific house work or chores is part of the ABA treatment plan for the member/identified
patient

 Provider travel time

 Transporting parents or non-patient family members

 Babysitting

 Respite for parents/family members

 Provider residing in the member’s home and functioning as live-in help (eg, in an au-pair
role)

 Peer-mediated groups or interventions

 Multiple family group therapy

 Training or classes for groups of parents of different patients

 Hippotherapy/equestrian therapy

 Pet therapy

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  Auditory Integration Therapy

 Sensory Integration Therapy

 Visual Field Analysis

Evidence Review

N/A

References

1. Warren, Zachary. McPheeters, Melissa. Sathe, Nila. et al. “A Systematic Review of Early Intensive Intervention for Autism
Spectrum Disorders.” Pediatrics 127.5 (2011): 1303-1311.

2. Agency for Healthcare Research and Quality. Therapies for Children with Autism Spectrum Disorders. Washington DC: Agency
for Healthcare Research and Quality, 2011.

3. Behavior Analyst Certification Board. Guidelines: Health Plan Coverage of Applied Behavior Analysis Treatment for Autism
Spectrum Disorder. Littleton, CO: Behavior Analyst Certification Board, 2012.

4. Hollander, Eric and Evodkia Anagnostou. Clinical Manual for the Treatment of Autism. Washington DC: American Psychiatric
Publishing, 2007.

5. Hollander, Eric, Alex Kolevzon, and Joseph T. Coyle. Textbook of Autism Spectrum Disorders. Washington DC: American
Psychiatric Publishing, 2011.

6. Hansen, Robin L. and Sally J. Rogers. Autism and Other Neurodevelopmental Disorders. Washington DC: American Psychiatric
Publishing, 2011.

7. Granpeesheh, Dorren. Tarbox, Jonathan. Dixon, Dennis. “Applied Behavior Analytic Interventions for Children with Autism: A
Description and Review of Treatment Research.” Annals of Clinical Psychiatry 21.3 (2009): 162-173.

8. Dawson, Geraldine. Rogers, Sally. Munan, Jeffrey et al. “Randomized Controlled Trial of an Intervention for Toddlers with
Autism: The Early Start Denver Model.” Pediatrics 125.1 (2010):17-23.

9. Up To Date. “Autism Spectrum Disorder in Children and Adolescents: Overview of Management.” www.uptodate.com
Accessed October 2018.

10. Washington State Health Care Authority. Health Technology Clinical Committee. Health Technology Assessment. Findings and
Coverage Decision. “Applied Behavioral Analysis (ABA or ABA Therapy) Based Behavioral Interventions for the Treatment of
Autism Spectrum Disorder.” Sept 16, 2011.

11. Bishop-Fitzpatrick, L. Minshew N.J. Eack, S.M. “A Systematic Review of Psychosocial Interventions for Adults with Autism
Spectrum Disorders.” Journal of Autism and Developmental Disorders 43.3 (2103):687-694.

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 12. Agency for Healthcare Research and Quality. Final Report: Therapies for Children with Autism Spectrum Disorders: Behavioral
Interventions Update. Washington DC: Agency for Healthcare Research and Quality, 2014.

13. American Academy of Child and Adolescent Psychiatry. “Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Autism Spectrum Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 53.2 (2014):
237-257.

History

Date Comments
11/10/14 New policy. Add to Mental Health section. Considered medically necessary when
criteria are met.

02/10/15 Annual Review. Policy Guidelines section updated with clarifying language to indicate
that, when deemed appropriate, functional analysis re-assessments are generally
conducted once every 6 to 12 months. Benefit Application section updated to specify
covered services for ABA for Autism Spectrum Disorders are those which are
represented by those codes listed within the Coding section, unless otherwise directed
by specific health stipulations.

04/14/15 Interim Update. Policy section updated with an additionally not medically necessary
statement addressing the use of ABA for conditions and criteria other than those
listed. “Any other state-licensed Behavior Analyst” added to the list of approved
providers of ABA within the Policy Guidelines and is considered to be equivalent.
Visual field analysis is added to the list of indications within the Benefit Application
section which are not considered to constitute ABA services. Additional ICD-10 codes
related to Autism Spectrum Disorder added to the Policy section.

10/13/15 Interim Update. Policy statement updated to indicate “lead therapist, or supervising
clinician” as an option to a program manager in facilitating this service, when provided
in conjunction with a therapists or therapist assistant. Clarification made to the
meaning of a “Board Certified Behavior Analyst (BCBA)” and variance of state licensure
requirements within the Policy Guidelines. “Multiple family group therapy” added to
the list of items outside of the scope of ABA services referenced in the Benefit
Application section, ICD-9 and ICD-10 codes added.

04/01/16 Annual Review, approved March 8, 2016. Policy updated within the Policy Guidelines
and Benefit application section to address services provided in the school setting.

07/01/16 Interim Update, approved June 14, 2016. Policy Guidelines section updated to indicate
that any provider with appropriate training in behavior analysis, or whose scope of
licensure includes behavior analysis, is a qualified ABA provider. Benefit application
section updated to indicate that direct service provision by telehealth modalities is
considered to be not medically necessary due to lack of credible scientific evidence.

09/01/16 Interim Update, approved August 9, 2016. Update to Policy Guidelines.

Page | 16 of 18 ∞
Date Comments
12/01/16 Interim Review, approved November 8, 2016. Updated policy statement with clarifying
language. Updated Benefit application section with telehealth criteria.

01/01/17 Interim Review, approved December 13, 2016. Clarification made to the Policy
Statement on comprehensive assessment. Updated the language in the Policy
Guidelines. Added codes S5108, S5109, S5110, S5111. Updated Benefit Application
criteria to clarify services not listed in the coding section aren’t covered services for
ABA for Autism Spectrum Disorders.

02/01/17 Annual Review, approved January 10, 2017. Updated language on individualized
treatment plan in the Policy Statement. Added codes 0362T and 0363T. No other
changes made.

04/01/17 Interim Review, approved March 14, 2017. Added coverage criteria clarifications to
Benefit Application section.

06/01/17 Interim Review, approved May 23, 2017. Policy moved into new format. Added note
that supervision of ABA must be provided by licensed behavior analysts in states in
which require that. Added statements that providing two different types of treatment
(ABA and non-ABA) simultaneously is not medically necessary, and providing ABA
treatment to more than one patient simultaneously (except for social skills groups) is
not medically necessary.

08/01/17 Interim Review, approved July 25, 2017. Clarifications made to policy statement. Added
additional comments for required state registration, certification or licensure of
therapy assistants and/or BCaBAs in some states. Added clarification regarding the
type of group therapy covered, the covered providers for group therapy, and the
number of group sessions per day. Added clarification regarding when team meetings
are covered. Added clarification regarding charting data and plotting graphs. Added
clarification that camp programs are not covered, with explanatory comments. Added
comment that direct treatment services to siblings together is not medically necessary.
Added preparation work to the list of activities that are not ABA services. Added
clarification that when accompanying or transporting a member to
appointments/activities, or assisting a member with schoolwork, because of significant
behavioral difficulties during such activities, the clinician must be present to provide
treatment, not just for control or containment.

10/01/17 Interim Review approved September 5, 2017. Minor addition in the Applied Behavior
Analysis section to allow for coverage of supervision conducted by Licensed Assistant
Behavior Analysts in states in which that function is within their legally-permitted
scope of practice.

12/01/17 Interim Review, approved November 9, 2017. Clarification added regarding services
not utilizing applied behavioral analysis techniques; they are either contract exclusions
or not medically necessary depending on the member’s contract language. Also added
clarification regarding school and school programs; these are not covered parts of
ABA.

03/01/18 Interim Review, approved February 27, 2018. Added clarification regarding when

Page | 17 of 18 ∞
Date Comments
individual treatment can be covered in a group setting. Also added clarification
regarding what is not covered for schools. Clarified BCaBAs criteria.

11/01/18 Annual Review, approved October 26, 2018. No changes to policy statement.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review
and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit
booklet or contact a member service representative to determine coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2018 Premera
All Rights Reserved.

Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members and their providers should consult the member
benefit booklet or contact a customer service representative to determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Page | 18 of 18 ∞
Discrimination is Against the Law Oromoo (Cushite):
Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa
Premera Blue Cross complies with applicable Federal civil rights laws and yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee
does not discriminate on the basis of race, color, national origin, age, odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa
disability, or sex. Premera does not exclude people or treat them differently ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf
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jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
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• Provides free aids and services to people with disabilities to communicate Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.
effectively with us, such as:
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• Written information in other formats (large print, audio, accessible Cet avis a d'importantes informations. Cet avis peut avoir d'importantes
electronic formats, other formats) informations sur votre demande ou la couverture par l'intermédiaire de
• Provides free language services to people whose primary language is not Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous
English, such as: devrez peut-être prendre des mesures par certains délais pour maintenir
votre couverture de santé ou d'aide avec les coûts. Vous avez le droit
• Qualified interpreters
d'obtenir cette information et de l’aide dans votre langue à aucun coût.
• Information written in other languages
Appelez le 800-722-1471 (TTY: 800-842-5357).
If you need these services, contact the Civil Rights Coordinator.
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Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen
If you believe that Premera has failed to provide these services or
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avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka
Civil Rights Coordinator - Complaints and Appeals
kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo.
PO Box 91102, Seattle, WA 98111
Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,
Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357
san ou pa gen pou peye pou sa. Rele nan 800-722-1471
Email AppealsDepartmentInquiries@Premera.com
(TTY: 800-842-5357).
You can file a grievance in person or by mail, fax, or email. If you need help
Deutsche (German):
filing a grievance, the Civil Rights Coordinator is available to help you.
Diese Benachrichtigung enthält wichtige Informationen. Diese
Benachrichtigung enthält unter Umständen wichtige Informationen
You can also file a civil rights complaint with the U.S. Department of Health
bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera
and Human Services, Office for Civil Rights, electronically through the
Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser
Office for Civil Rights Complaint Portal, available at
Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten
U.S. Department of Health and Human Services
zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in
200 Independence Avenue SW, Room 509F, HHH Building
Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471
Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD)
(TTY: 800-842-5357).
Complaint forms are available at
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Hmoob (Hmong):
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Getting Help in Other Languages tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv
thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue
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Cross. There may be key dates in this notice. You may need to take action dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj
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have the right to get this information and help in your language at no cost. ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau
Call 800-722-1471 (TTY: 800-842-5357). ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471
(TTY: 800-842-5357).
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ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት
maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue
አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ። Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar.
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Questo avviso contiene informazioni importanti. Questo avviso può contenere
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語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。
Chiama 800-722-1471 (TTY: 800-842-5357).

037338 (07-2016)
日本語 (Japanese): Română (Romanian):
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alguno. Llame al 800-722-1471 (TTY: 800-842-5357).
ਪੰ ਜਾਬੀ (Punjabi): Tagalog (Tagalog):
ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ.ੈ ਇਸ ਨੋ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲƒ ਤੁਹਾਡੀ Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang
ਕਵਰਜ ੇ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱ ਤਵਪਰਨ ੂ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon
ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤਸੀ ੁ ਜਸਹਤ ਕਵਰਜ ੇ ਿਰਖਣੀੱ ਹਵੋ ੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵਚੱ ਮਦਦ ਦੇ tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue
Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring
ਇਛੱ ੁਕ ਹੋ ਤਾਂ ਤ ੁਹਾਨੰ ੂ ਅੰ ਤਮ ਤਾਰੀਖ਼ ਤƒ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੱ ੁਕਣ ਦੀ ਲੜੋ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੰ ੂ mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang
ਮਫ਼ਤੁ ਿਵਚ
ੱ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪਾਪਤ ੍ਰ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na
800-722-1471 (TTY: 800-842-5357). walang gastos. May karapatan ka na makakuha ng ganitong impormasyon
at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471
‫( فارسی‬Farsi): (TTY: 800-842-5357).
‫اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم‬. ‫اين اعالميه حاوی اطالعات مھم ميباشد‬
‫ به تاريخ ھای مھم در‬.‫ باشد‬Premera Blue Cross ‫تقاضا و يا پوشش بيمه ای شما از طريق‬ ไทย (Thai):
‫شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه‬. ‫اين اعالميه توجه نماييد‬ ประกาศนมขอมลสาคญ
้ี ี ้ ู ํ ั ประกาศนอาจมขอมลทสาคญเกยวกบการการสมครหรอขอบเขตประกน
้ี ี ้ ู ่ี ํ ั ่ี ั ั ื ั
‫شما حق‬. ‫ به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد‬،‫ھای درمانی تان‬ สขภาพของคณผาน
ุ ุ ่ Premera Blue Cross และอาจมกาหนดการในประกาศน
ีํ ี ้ คณอาจจะตอง
ุ ้
‫ برای کسب‬.‫اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد‬
‫( تماس‬800-842-5357 ‫ تماس باشماره‬TTY ‫ )کاربران‬800-722-1471 ‫اطالعات با شماره‬ ดาเนนการภายในกาหนดระยะเวลาทแนนอนเพอจะรกษาการประกนสขภาพของคณหรอการชวยเหลอท
ํ ิ ํ ่ี ่ ่ื ั ั ุ ุ ื ่ ื ่ี
.‫برقرار نماييد‬ มคาใชจาย
ี ่ ้ ่ คณมสทธทจะไดรบขอมลและความชวยเหลอนในภาษาของคณโดยไม่
ุ ี ิ ิ ่ี ้ ั ้ ู ่ ื ้ี ุ มีคาใชจาย
่ ้ ่ โทร
800-722-1471 (TTY: 800-842-5357)
Polskie (Polish):

To ogłoszenie może zawierać ważne informacje. To ogłoszenie może

Український (Ukrainian):
zawierać ważne informacje odnośnie Państwa wniosku lub zakresu Це повідомлення містить важливу інформацію. Це повідомлення
świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na може містити важливу інформацію про Ваше звернення щодо
kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie страхувального покриття через Premera Blue Cross. Зверніть увагу на
przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub ключові дати, які можуть бути вказані у цьому повідомленні. Існує
pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej імовірність того, що Вам треба буде здійснити певні кроки у конкретні
informacji we własnym języku. Zadzwońcie pod 800-722-1471 кінцеві строки для того, щоб зберегти Ваше медичне страхування або
(TTY: 800-842-5357). отримати фінансову допомогу. У Вас є право на отримання цієї
інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за
Português (Portuguese): номером телефону 800-722-1471 (TTY: 800-842-5357).
Este aviso contém informações importantes. Este aviso poderá conter
informações importantes a respeito de sua aplicação ou cobertura por meio Tiếng Việt (Vietnamese):
do Premera Blue Cross. Poderão existir datas importantes neste aviso. Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông
Talvez seja necessário que você tome providências dentro de tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua
determinados prazos para manter sua cobertura de saúde ou ajuda de chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông
custos. Você tem o direito de obter esta informação e ajuda em seu idioma báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn
e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357). để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có
quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình
miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).