Description
Applied Behavioral Analysis (ABA) for Autism Spectrum Disorder (ASD)
ASD is a medical, neurobiological, and developmental disorder, characterized by three core deficit areas: social interactions, social communication, and restricted, repetitive patterns of behavior. ABA is the behavioral treatment approach most used with children with ASD. ABA techniques include Discreet Trial Training, Incidental Teaching, Pivotal Response Training, and Verbal Behavioral Intervention. The PECS (Picture Exchange Communication System) is based upon ABA concepts and is used for improving communication deficits. 

ABA for ASD includes efforts to extinguish negative behaviors, and to replace these with positive behaviors by improving skills, based upon Skinnerian concepts of conditioned responses. Another focus would be the development of the ability to generalize concepts already learned to novel situations. Aside from a concentration on the core symptoms, there is a focus on attention and initiation as well. All involve a structured environment, predictable routines, functional as opposed to standardized treatment, a transition plan and significant family involvement. At the initial evaluation, target symptoms are identified, with designated interventions. There is also a need to provide an assessment mechanism at specified intervals.

ABA services for young children are often referred to as Early Intensive Behavioral Intervention (EIBI). EIBI targets cognition, language, social skills, etc. These services have typically been provided to children ages 8 and under for a duration of two to three years. During an average week, these services may be provided for up to 40 hours. Although the literature is clear that 10 hours per week results in a less robust therapeutic response, it remains unclear as to the optimal number of hours/week. After these preschool years, services may be provided by the child’s school, as well as in the child’s home. For children above the age of 10 years, services requested may focus on the development of social skills. Much of the ABA research has focused on children in the age range 2 – 7.

Policy
ABA services are considered MEDICALLY NECESSARY when performed to meet the functional needs of a patient with Autism Spectrum Disorder.

Policy Guidelines

• A DSM diagnosis of Autism Spectrum Disorder (ICD-10 of F84.0).
• There is a signed treatment plan from the member’s licensed physician, nurse practitioner or physician assistant. This includes required testing and results, treatment plan with specified goals, medical history (which may include records relating to the initial diagnosis of ASD, or any co-morbid medical conditions) and history of behavioral therapy.
• The ABA services do not duplicate services that directly support academic achievement goals that may be included in the member’s educational setting or the academic goals encompassed in the member’s Individualized Education Plan (IEP)/Individualized Service Plan (ISP).
• The ABA services recommended do not duplicate services provided or available to the member by other medical or behavioral health professionals. Examples include but are not limited to behavioral health treatment such as individual, group, and family therapies; occupational, physical, and speech therapies.
• Approved treatment goals and clinical documentation must be focused on active ASD core symptoms, substantial deficits that inhibit daily functioning, and clinically significant aberrant behaviors. This includes a plan for stimulus and response generalization in novel contexts.

Criteria to Initiate Care

All of the following criteria must be met:

• A treatment plan with the diagnosis of Autism Spectrum Disorder diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism. DSM-5-TR criteria are met for autism including severity scale.
• Clinical interview with the member and/or family/caregiver
• Completed psychological testing results performed by a licensed clinical psychologist, licensed psycho-educational specialist, psychiatrist, or developmental pediatrician (Testing results that are completed by a school psychologist and are reviewed and verified by a clinical psychologist, developmental pediatrician, pediatric neurologist, board certified pediatrician, psychiatrist or medical doctor experienced in the diagnosis of ASD can satisfy this psychological testing requirement.):
• DSM-5-TR Criteria met for autism including severity scale
• One of the following standard psychiatric assessments: ADOS-2, ADI (Autism Diagnostic Interview-Revised), Diagnostic Interview for Social or Communication Disorders (DISCO), or Childhood Autism Rating Scale (CARS-2-HF or CARS-2), and two additional evidenced-based autism spectrum disorder assessments/tests (examples of evidence-based assessments/tests below):
  • • Vineland Adaptive Scale (within 95 percent confidence interval)
    • Autism Diagnostic Interview-Revised (ADI-R)
    • Social Communications Questionnaire (SCQ)
    • Childhood Autism Rating Scale (CARS)
    • Autism Behavior Checklist (ABC)
    • Modified Checklist for Autism in Toddlers (M-CHAT)
    • Gilliam Autism Rating Scale (GARS)
• BCBA/BCaBA assessment and program plan that must include the following elements:
  • ABLLS, AFLS, EFL or VB-MAPP
  • Behavioral observation in one or more settings, presenting problems, symptoms and functional deficits, anticipated outcomes stated as measurable goals related to each specific problematic behavior or skill deficit (language, imitation, social skills, cooperation, etc.)
  • Achievement timeframes.
  • Submission of signed FCM-287 ABA Service Provider Request form
• Assessment is to be dated within 45 days prior to service request.
• If request includes non-standard codes additional documentation is required to support the request for the non-standard codes.

Criteria for Continued Care

All of the following must be met:

• Treatment plan signed and submitted by licensed physician, nurse practitioner or physician assistant which must include the following required elements:
• BCBA/BCaBA assessment and program plan that must include the following elements:
• ABLLS, AFLS, EFL or VB-MAPP
• Anticipated outcomes stated as measurable goals related to each specific problematic behavior or skill deficit (language, imitation, social skills, cooperation, etc.).
• Achievement timeframes
• Amount and type of parent/caregiver participation, as applicable to member
• Date of every ninety-day review and annual re-development
• Signature, title and date by the multidisciplinary team members including the parent and/or caregiver.
• Submission of the last two 90-Day Progress Summaries including the following information: specific objective(s) towards which the 90 days has focused, specific treatment activities and interventions, goals that have been met, graphs of goals and objective demonstrating progress, explanation of delayed progress toward goals, amount and time of parent/caregiver participation/demonstration of how operational control will be transferred to caregivers, summary of treatment plan for the upcoming 90-days and signature and title, and date by the multidisciplinary team members to include the parent and/or caregiver.
• Assessment is to be dated within 45 days prior to service request.
• If request includes non-standard codes additional and/or an increase in hours documentation is required to support the request. All requests for nonstandard codes and increased hours will be reviewed.

Criteria for Discharge From Care

One of the following criteria must be met:

• Treatment is making the symptoms or negative behavior(s) persistently worse.
• No meaningful, measurable change has been documented in the individual’s functioning and/or behavior(s) for a period of at least six months of optimal treatment.
• he individual has achieved adequate stabilization of functions and/or the challenging behavior(s), and less-intensive modes of treatment are appropriate. It is appropriate to request to restart treatment if measurable deterioration in functioning and/or behavior(s) occurs with less intensive modes of treatment.
• The individual’s parent(s) and/or caregiver(s) demonstrate adequate skill in administering a long-term home-based program.
• The individual demonstrates an inability to maintain long-term gains from the proposed treatment plan.
• The intervention is considered respite, shadow or companion services.

When ABA is considered NOT medically necessary:

• When the criteria outlined above are not met.

The following programs are considered INVESTIGATIONAL because its clinical value has not been established:

• Auditory Integration Therapy
• Facilitated Communication
• Developmental Individual-difference Relationship-based (DIR/Floortime) model
• Relationship Development Intervention
• Holding Therapy
• Movement Therapies
• Music Therapy
• Pet Therapy
• Psychoanalysis
• Son Rise Program
• Scotopic Sensitivity Training
• Sensory Integration Therapy
• Neurotherapy (EEG biofeedback)
• Gluten and casein free diets, mega-vitamin therapy, chelation of heavy metals, anti-fungal drugs for presumed fungal infection and secretin administration
• Educational-based services including but are not limited to, TEAACH, Higashi Schools/Daily Life, Individual Support Program, LEAP, SPELL, Waldon, Hanen, Early Bird, Bright Start, Social Stories, Gentle Teaching, Response Teaching Curriculum and Developmental Intervention Model

Medical Record Documentation Requirements

Please also see CAM 191 Medical Records Documentation Standards.

Providers must maintain medical records that comport with the record-keeping standards of their profession. However, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, his or her medical records must also comply with the following requirements:

• Date
• Face to face time start and end time
• Individuals present during the visit
• Brief description of services provided
• Clinical note on the recipient’s behavior
• Place of service/delivery setting
• Any communication with guardians/ caregivers
• Signature of rendering provider with title
• All elements must be documented in legible handwriting.
• Corrections to the medical record will be considered when all of the following criteria are met:
  • Legally amended.
    • Note: For guidelines regarding legal corrections and amendments to medical records, please see "Documentation Guidelines — Amended Records," below. 
  • Amended within 30 days of date of service (outpatient) or date of discharge (inpatient)
  • Amended prior to claims submission and/or medical review
  • Amendment contains signature, date of amendment, and reason for the addition or clarification of information being added to the medical record

The following documentation will not be considered when determining the validity of services billed and the processing of the claim:

• Changes or amendments which appear in the record more than 30-days after the date of service/discharge
• Changes or amendments made after a records request
• Changes or amendments made after a payment determination

Elements of a complete medical record may include:

• Physician orders, and/or certification of medical necessity.
• Patient questionnaires associated with physician services.
• Progress notes of another provider that are referenced in your own note.
• Treatment logs.
• Related professional consultation reports.
• Procedure, lab, x-ray and diagnostic reports.

Provider Qualifications

• Reimbursement will be made only to the BCBA-D or the BCBA certified individual, who will assume all clinical and financial responsibility for all therapists. If a claim is for an out of state service from an in-network  provider, these rules may not be applicable.
• Eligibility for network inclusion shall be based on BCBA-D or BCBA certification.
• Individuals with BCaBA certification are only accepted if they are appropriately supervised by a BCBA-D or BCBA and part of an established participating ABA service provider group.

Definitions
Autism Spectrum Disorder refers to a disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. This disorder is best characterized as neurobiological disorder of uncertain etiology, with symptom onset in the first years of life. Heritability is polygenic and estimated to be 90 percent. The primary phenomenon in ASD is severe impairment in development of social skills. Other deficits that may be observed include failure to initiate play or social interaction, inability to generalize learned behavior to new situations, failure to share attention with others, poor sleep, temper tantrums, hyperactivity, etc.

Autism is characterized by a triad of deficits in social skills, communication/language abilities and impairments in imaginative play. Additionally, there are often stereotypic behaviors, restricted interests and activities. Significant numbers of patients also experience intellectual disability and, as one would expect, there is a relationship between cognition and response to treatment. 

Applied Behavioral Analysis for ASD refers to behavioral modification using ABA techniques, or the Lovaas Method, to target cognition, language and social skills. Techniques used within this paradigm include Discreet Trial Training, Incidental Teaching, Pivotal Response Training and Verbal Behavioral Intervention. ABA service for younger children is often referred to as Early Intensive Behavioral Intervention (EIBI). 

Board Certified Behavior Analyst^® (BCBA^®) refers to the person who is certified by the BACB (Behavioral Analyst Certification Board) and who is responsible for the administration of appropriate assessment tools, plan/notebook development, implementation and oversight, as well as workshop/training and oversight of all staff, reviewing data, updating plan, and troubleshooting. This person also conducts six-month assessments that include the Assessment of Basic Language and Learning Skills (ABLLS)–Assessment of Functional Living Skills (AFLS), Essential for Living (EFL) or Verbal Behavior Milestones Assessment and Placement (VB-MAPP), and a summary of treatment plan goals met and unmet related to specific behaviors, including, but not limited to, language, imitation, social skills, and cooperation, as well as periodic re-assessments of progress and problems noted.

Board Certified Assistant Behavior Analyst^® (BCaBA^®) refers to the person skilled in ABA techniques and is responsible for assessing progress via weekly monitoring utilizing highly structured formats and data review. BCBAs may delegate services listed above to a BCaBA who has been credentialed by CBA and is receiving required supervision. CBA requires that rendering providers possess a four-year college degree and may or may not be certified as BCBA. This person ensures that a RBT is well trained and acts as a liaison between the family and treatment team. 

Registered Behavior Technician ^TM (RBT^TM) refers to the person trained in ABA techniques who is responsible for working directly with the child and for following a pre-set program plan for implementing skill acquisition and behavior reduction procedures and recording program data.

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Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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