Applied behavior analysis medical necessity guide

Note: If there is a discrepancy between this guideline and a member's plan of benefits, the benefits plan
will govern. Also, a state or federal government, or CMS for Medicare and Medicaid members,1
may mandate some coverage (and coverage limits).

Purpose
This applied behavior analysis (ABA) guideline is for use by clinicians. It’s meant to aid in the decision-
making process to determine the type and intensity of services a member with a condition on the Autism
Spectrum needs. If the treatment is provided in an inpatient, residential or partial hospitalization setting,
applicable medical necessity for coverage at that level of care is used and specific authorization for ABA
is not needed in addition. Reviews using other applicable medical necessity criteria occur at a frequency
commensurate with the level of care. Prior to discharge from one of these higher levels of care, a review
using the guideline below for medical necessity of ABA is needed.

Guideline development
These guidelines come from extensive review of the literature on the use of applied behavior analysis to
treat Autism Spectrum Disorder and a comparative review of the guidelines of other health insurers. A
multidisciplinary committee of health care professionals within and external to Aetna Behavioral Health
developed and approved the guidelines based on these reviews. The guidelines are based upon the
reviews and known best practices in the treatment of Autism Spectrum Disorder, including:
• The requirement for a complete assessment using validated tools and standardized developmental
norms
• Focused interventions
• Caregiver participation
• Repeated measurement with standardized measures to assess progress

Philosophy
Applied behavior analysis is a scientifically supported model of treatment to remediate the functional
impairments typically found in people with Autism Spectrum Disorder (ASD). It is a time-limited treatment
that should result in progressive, measurable gains in functioning on a standardized measure.

1
Exhibit A, attached to this guide, addresses medical necessity review for plans in Maryland subject to the law of the
state. Other state laws and regulations may apply in other states.

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 Type, duration and intensity

ABA intervention Definition Typical Typical Typical

type age range intensity duration
Skills and behaviors in multiple affected
Comprehensive domains are targeted for treatment, 0-7 years 10-25 1-2 years
which often include maladaptive hrs/week
behaviors.

Services are directed to a limited number All ages 1-20 Variable

Focused of skill and behavioral targets. hrs/week
1-4 years

Essential elements
1. There is a DSM-V diagnosis of Autism Spectrum Disorder (ICD‐10/ F84.0; F84.3 – F84.9) obtained
by an appropriate provider (i.e. licensed psychologist/psychiatrist, physician, or other health care
professional qualified to diagnose mental health conditions within their scope of practice).
2. There are identifiable target behaviors having an impact so the member cannot adequately
participate in developmentally appropriate activities such as school. Or there may be a significant
risk of harm to self or others. The ABA is not custodial in nature (which Aetna defines as care
provided when the member “has reached the maximum level of physical or mental function and
such person is not likely to make further significant improvement” or “any type of care where the
primary purpose of the type of care provided is to attend to the member’s daily living activities
which do not entail or require the continuing attention of trained medical or paramedical
personnel.”) Plan documents may have variations on this definition and need to be reviewed.
3. There is engagement and commitment from parent(s) (or guardians) to participate in
treatment to generalize gains.
4. There is a time-limited, individualized treatment plan developed that is member-centric,
strengths‐specific0 family‐focused0 community‐based0 multi‐system0 culturally competent,
and least intrusive. This treatment plan has specific target behaviors that are clearly defined:
frequency, rate, symptom intensity or duration, or other objective measures of baseline levels
are recorded, and quantifiable criteria for progress are established. The plan describes
behavioral intervention techniques appropriate to the target behavior, reinforcers selected,
and strategies for generalization of learned skills are specified. And there is documentation of
planning for transition through the continuum of interventions, services and settings, as well as
titration and discharge criteria.
5. There is a review of the member’s history0 as well as ongoing collaboration and coordination with
existing providers and/or the school district, as applicable. There is involvement of, or referrals to,
appropriate health care, community or supplemental resources.
6. Services must be provided directly or billed by: licensed behavior analysts (in states with
behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists
where behavior analysis is within their scope of practice definition, unless state mandates, plan

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 documents or contracts require otherwise. If state mandates, plan documents or contracts
allow authorization for services that are not directly provided by individuals licensed by the
state or certified by the Behavior Analyst Certification Board as noted above, there must be
supervision and direction of the unlicensed or non‐certified providers in line with practice
standards, unless state mandates, plan documents or contracts require otherwise.

Medical necessity criteria to initiate applied behavior analysis

All the following criteria must be met:
1. Essential elements are met.
2. There is demonstration of functional impairment on a standardized scale of functioning in the past
12 months. For instance, the Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior
Assessment Scale (ABAS), VB-MAPP or ABLLS. The impairment must be at least one standard
deviation below the population mean OR represent a significant risk of harm to self or others.
3. Parent(s) (or guardians) will be provided necessary support and training to reinforce interventions
and generalize gains.
4. The level of impairment (calculated below) justifies the number of hours requested.

Assessment of symptom severity

(This can be used as a guide.)
None Mild Moderate Severe
<1 SD >1 SD >1.5 SD >2 SD
below below below below
Functional impairment 0 1 to 4 4 to 7 7 to 10
Hours/Wk Hours/Wk Hours/Wk Hours/Wk
Maladaptive behavior: aggression0 self‐injury0
property destruction, restrictive/repetitive
behaviors and interests; abnormal, inflexible or
intense preoccupations
Social communication: Problems with expressive
or receptive language, poor understanding or use
of non‐verbal communications0 stereotyped or
repetitive language, lack of social/emotional
reciprocity, failure to seek or develop shared
social activities
Self‐care: Difficulty recognizing danger/risks, or
advocating for self; problems with
grooming/eating/toileting skills which are
impeded by symptoms of Autism
Based on functional impairment and assessment of symptom severity, additional authorization may be
provided for QHP protocol modification and direction at 1 to 2 hours per 10 hours of treatment by
protocol, as well as authorization for caregiver training.

All four criteria above must be evaluated. Based on scientific literature and the Aetna clinician’s
judgment following their review, the initial authorization may be for up to 30 hours per week for
Comprehensive ABA intervention of less than 2 years, or up to 25 hours per week for Focused ABA
intervention, up to 6 consecutive months, unless state mandates dictate otherwise, or there is sufficient

Proprietary
 clinical support for more hours. Further clinical review (by a medical director or clinical consultant) may be
sought for requests for more hours than are supported by the available clinical information.

Medical necessity criteria to continue applied behavior analysis

All the following criteria must be met:
1. Essential elements are still met.
2. Re-evaluation of interventions and progress has been performed (every six months) to assess the
need for ongoing ABA; AND a repeated validated assessment (e.g., Vineland, ABAS, VB-MAPP or
ABLLS) has been done every 6-12 months to demonstrate response to intervention.
3. The frequency of the target behavior has improved since the last review, or if not, there has been
modification of the treatment, additional assessments have been conducted, and/or there has
been appropriate consultations from other staff or experts.
4. Parent(s) (or guardians) will have measurable goals that work to reinforce interventions and
generalize gains across multiple settings and allow progress to be maintained over time as the
treating professional fades out.
5. The treatment plan documents a gradual tapering of higher intensities of intervention and a
shifting to supports from other sources (school, as an example) as progress occurs.
6. The level of impairment (calculated using the Assessment of Symptom Severity above) justifies
the number of hours requested for ABA.

All six criteria above must be evaluated. Based on scientific literature and the Aetna clinician’s judgment
following their review of treatment progress and response to intervention, the continued authorization is
adjusted (up or down) based on clinical justification or may be continued for up to 30 hours per week for
Comprehensive ABA intervention of less than 2 years, or up to 25 hours per week for Focused ABA
intervention, up to 6 consecutive months, unless state mandates dictate otherwise, or there is sufficient
clinical support for more hours. Further clinical review (by a medical director or clinical consultant) may be
sought for requests for more hours than are supported by the available clinical information.

Termination of applied behavior analysis

Termination: A member’s progress is to be evaluated every six months. A member not making progress
will be transitioned to other appropriate services. When it becomes clear that a treatment is ineffective, or
the treatment is no longer needed, this must be communicated to the family and provider.

One of the following criteria must be met:

1. The essential elements are no longer met.
2. There has been improvement of two or more standard deviations in multiple domains.
3. There has been improvement of one or more standard deviations in multiple domains in a Focused
ABA Intervention plan.
4. There has been improvement of less than one standard deviation in all domains for successive
authorization periods.
5. Parent(s) (or guardians) have not participated in treatment for successive authorization periods.

Proprietary
 References

Behavior Analyst Certification Board. (2014). Applied Behavior Analysis Treatment of Autism Spectrum
Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.).

Behavior Analyst Certification Board. (2019). Clarifications Regarding Applied Behavior Analysis Treatment
of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.).

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Cohen, H., Amerine-Dickens, M., & Smith, T. (2006). Early intensive behavioral treatment: replication of the
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Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2010).
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Doehring, P., Reichow, B., Palka, T., Phillips, C., & Hagopian, L. (2014). Behavioral approaches to managing
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Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral treatment at school for 4- to 7­
year-old children with autism: A 1-year comparison controlled study. Behavior Modification, 26(1), 49–68.
https://doi.org/10.1177/0145445502026001004

Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2007). Outcome for children with autism who began intensive
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Eldevik S., Hastings R., Hughes J., Jahr E., Eikeseth S., & Cross S. (2009). Meta-analysis of Early Intensive
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Eldevik, S., Hastings, R., Hughes, J., Jahr, E., Eikeseth, S., & Cross, S. (2010). Using participant data to
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on intellectual and developmental disabilities, 115(5), 381–405. https://doi.org/10.1352/1944-7558­
115.5.381

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 Eldevik S., Hastings R., Jahr E., & Hughes J. (2012). Outcomes of behavioral intervention for children with
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doi: 10.1007/s10803-011-1234-9

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R., McEachin, J., Yoder, P., & Autism Partnership Foundation. (2017). An evaluation of a behaviorally based
social skills group for individuals diagnosed with autism spectrum disorder. Journal of Autism and
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 Exhibit A: Medical necessity review for
Maryland plans
Pursuant to Maryland insurance regulation COMAR 31.10.39, Aetna will apply the following
criteria when assessing medical necessity for applied behavior analysis for plans subject to
Maryland law.

1. The child’s primary care provider or specialty physician must perform a comprehensive
evaluation identifying the need for applied behavior analysis for the treatment of Autism or
Autism Spectrum Disorder.

2. Such primary care provider or specialty physician must prescribe the treatment. Such
prescription must include specific treatment goals.

3. Such treatment shall be reviewed annually for medical necessity with the primary care
provider or specialty physician, and in consultation with the applied behavior analysis
provider. Such utilization review shall include:

a. Documentation of benefit to the child

b. Identification of new or continuing treatment goals

c. Development of a new or continuing treatment plan

4. The applied behavior analysis provider must be licensed, certified or otherwise authorized
under the Maryland Health Occupations Article or similar licensing, certification or authorization
requirements of another state or U.S. territory where the services are provided.

5. Coverage may be subject to limitations in a health benefit plan relating to coordination of

benefits, participating provider requirements, restrictions on services provided by familyor
household members, case management provisions, and copayments, coinsurance and
deductible amounts.

___________________________________
Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat
people differently based on their race, color, national origin, sex, age, or disability.

We provide free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the
number on the back of your member ID card.

Proprietary
 If you believe we have failed to provide these services or otherwise discriminated based on a protected class
noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA
93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
CRCoordinator@Aetna.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S.
Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
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Marathi

Ņan bōk jipan̄ kōn kajin ilo an ejjeļọk wōņean n̄ an kwe, kwōn kallok nōṃba eo ilo
Marshallese
kaat in ID eo aṃ.
Micronesian- Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw
Ponapean doaropwe en ID.
Mon-Khmer,
Cambodian
T’11 ni nizaad k’ehj7 bee n7k1 a’doowo[ doo b33h 7l7n7g00 naaltsoos bee atah
Navajo
n7l98go nanitin7g77 bee n44ho’d0lzin7g77 b44sh bee hane’7 bik1’7g77 1aj8’ h0lne’.
Nepali
Të kɔɔr yïn ran de wɛ̈ɛr̈ de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke yïn cɔl ran ye kɔc
Nilotic-Dinka
kuɔny në namba de abac tɔ̈ në ID kard duɔ̈n de tïït de nyin de panakim kɔ̈u.
Norwegian
Proprietary
For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
 Pennsylvanian-
Dutch Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
Persian Farsi .‫ ﺑﺎ ﺷﻤﺎره ﻗﯿﺪ ﺷﺪه روی ﮐﺎرت ﺷﻨﺎﺳﺎﯾﯽ ﺧﻮد ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ‬،‫ﺑﺮای دﺳﺘﺮﺳﯽ ﺑﮫ ﺧﺪﻣﺎت زﺑﺎن ﺑﮫ طﻮر راﯾﮕﺎن‬
Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer
Polish
podany na karcie identyfikacyjnej.
Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no
Portuguese
seu cartão de identificação.

Punjabi

Romanian Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.
Для того чтобы бесплатно получить помощь переводчика, позвоните по
Russian
телефону, приведенному на вашей идентификационной карте.
Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i
Samoan
luga o lau pepa ID.
Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj
Serbo-Croatian
kartici.
Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura
Spanish
en su tarjeta de identificación.
Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon
Sudanic Fulfulde
windi ha do ɗerowol maaɗa.
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya
Swahili
kitambulisho.

Syriac-Assyrian

Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang
Tagalog
numero sa iyong ID card.
Telugu
Thai
Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa,
Tongan
telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.
Turkish Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.
Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на
Ukrainian
вашій ідентифікайній картці.
Urdu
Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID
Vietnamese
của quý vị.
Yiddish .‫ קארטל‬ID ‫ רופט דעם נומער אויף אייער‬,‫צו באקומען שפראך סערוויסעס פריי פון אפצאל‬
Yoruba Láti ráyèsí àwọn iṣẹ́ èdè fún ọ lọ́fẹ̀ ẹ,́ pe nọ́mbà tó wà lórí káàdì ìdánimọ̀ rẹ.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of
companies, including Aetna Life Insurance Company and its affiliates (Aetna).

©2021 Aetna Inc.

48.02.901.1 (6/21)

Proprietary