I.
When ABA is a covered benefit, the initiation of services is
considered medically necessary for members meeting all of the following
criteria:
A.
Diagnosis of ASD (F84.0 – F84.9) has been made by a physician (primary
care physician, neurologist, developmental pediatrician, psychiatrist, licensed
psychologist or other type of approved licensed medical doctor qualified to
diagnose ASD) prior to request for services, and confirmed by one of the
following diagnosis specific tests/screening tools:
1.
Checklist for Autism in Toddlers (CHAT);
2.
Modified Checklist for Autism in Toddlers/Modified Checklist for Autism
in Toddlers, Revised with follow–up (M–CHAT/M–CHAT–R/F);
3.
Screening Tool for Autism in Two–Year Olds (STAT);
4.
Social Communication Questionnaire (SCQ) (recommended for children ≥
four–years);
5.
Autism Spectrum Screening Questionnaire (ASSQ);
6.
Childhood Autism Spectrum Test, formerly known as the Childhood
Asperger’s Syndrome Test (CAST);
7.
Krug Asperger`s Disorder Index (KADI);
8.
Autism Diagnostic Observation Schedule/Autism Diagnostic Observation
Schedule – 2nd edition (ADOS/ADOS–2);
9.
Autism Diagnostic Interview Revised (ADI–R);
10.
Childhood Autism Rating Scale/
Childhood Autism Rating Scale – 2nd
edition (CARS/CARS–2);
11.
Gilliam Autism Rating Scale (GARS);
12.
A valid form of approved evidenced based assessment result/summary.
B.
A DSM–IV or DSM–5 diagnosis validates ASD, identifying the justified need
for ABA services and falls within one or both of the following categories:
1.
Social interaction and social communication as manifested by any of the
following:
a.
Child shows little interest in making friends;
b.
Initiates social interactions primarily to have immediate needs met
(e.g., to get food, preferred toy);
c.
Tends not to share accomplishments and experiences;
d.
Lack of eye contact;
e.
Absent or limited and atypical gestures (e.g., using someone’s hand as a
tool for opening the door);
f.
Loss of language.
2.
Restricted interests and repetitive behaviors as manifested by any of the
following:
a.
Intensely repetitive motor movements or use of objects;
b.
Consumed with a single item, idea, or person;
c.
Difficulty with changes in environment or transitions from one situation
to another;
d.
Frequent tantrums;
e.
Aggressive or self–injurious.
C.
The treatment plan is built upon individualized goals and projected time
to achieve those goals with measurable objectives tailored to the member.
Treatment is either focused or comprehensive based on the following guidelines:
1.
Focused ABA treatment meets both of the following:
a.
Identifies hourly breakout for individual and group hours ranging from 10
– 25 hours per week including 1:1 direct and indirect, group, supervision, and
caregiver training;
b.
Identifies measureable outcomes for every goal and objective.
2.
Comprehensive ABA treatment plan meets all of the following:
a.
Identifies hourly breakout for individual and group hours ranging from 25
– 40 hours per week inclusive of all 1:1 direct and indirect, group,
supervision, and caregiver training;
b.
Identifies measureable outcomes for every goal and objective;
c.
Hours of therapy per day are individualized with the goal of increasing
or decreasing the intensity of therapy as the member’s ability to tolerate and
participate permits.
D.
The plan of care includes an initial discharge plan outlining desired
outcomes for knowing when the member has attained their full treatment goals and
discharge can likely occur;
E.
A description of roles and responsibilities of all providers and
effective dates for behavioral targets that must be achieved prior to the next
phase should be specified and coordinated with all providers, member, and family
members;
F.
Parent or caregiver training and support is incorporated into the
treatment plan;
G.
Interventions are consistent with ABA techniques.
II.
The continuation of ABA services is considered medically necessary
when all of the following criteria are met:
A.
The member continues to meet criteria for ASD diagnosis;
B.
There is reasonable expectation that the member will benefit from the
continuation of ABA therapy, as evidenced by mastery of skills defined in
initial plan, or a change of treatment approach from the initial plan;
C.
Interventions are consistent with ABA techniques;
D.
The treatment plan with documentation of progress towards meeting goals
is submitted for review every 3 – 6 months, or as state-mandated;
E.
The number of service hours necessary to effectively address the
challenging behaviors is listed in the treatment plan and considers the member’s
age, school attendance requirements, and other daily activities when determining
the number of hours of medically necessary direct service, group and supervision
hours;
F.
A description of roles and responsibilities of all providers and
effective dates for behavioral targets that must be achieved prior to the next
phase should be specified and coordinated with all providers, member, and family
members;
G.
Treatment hours are subsequently increased or decreased based on response
to treatment and current needs;
H.
Treatment is not making the symptoms worse;
I.
There is a reasonable expectation, based on the member’s clinical history
that withdrawal of treatment will result in decompensation/loss of progress
made, or recurrence of signs and symptoms.
Codes
Used In This BI:
|
CPT®* Code |
Code Description |
|
97151 |
Behavior identification assessment, administered by a physician or other
qualified health care professional, ea 15 mn of the physician`s or other
qualified health care professional`s time face–to–face
with patient and/or guardian(s)/caregiver(s) administering assessments
and discussing findings and recommendations, and non–face–to–face
analyzing past data, scoring/ interpreting the assessment, and preparing
the report/treatment plan |
|
97152 |
Behavior identification–supporting
assessment, administered by 1 tech under the direction of a physician or
other qualified health care professional, face–to–face
with the patient, ea 15 mn |
|
97153 |
Adaptive behavior treatment by protocol, administered by tech under the
direction of a physician or other qualified health care professional,
face–to–face
with 1 patient, ea 15 mn |
|
97154 |
Group
adaptive behavior treatment by protocol, administered by tech under the
direction of a physician or other qualified health care professional,
face–to–face
with 2+ patients, ea 15 mn |
|
97155 |
Adaptive behavior treatment with protocol modification, administered by
physician or other qualified health care professional, which may include
simultaneous direction of technician, face–to–face
with 1 patient, ea 15 mn |
|
97156 |
Family
adaptive behavior treatment guidance, administered by physician or other
qualified health care professional (with or w/out the patient present),
face–to–face
with guardian(s)/caregiver(s), ea 15 mn |
|
97157 |
Multiple–family group adaptive behavior
treatment guidance, administered by physician or other qualified health
care professional (w/out the patient present), face–to–face
with multiple sets of guardians/caregivers, ea 15 mn |
|
97158 |
Group
adaptive behavior treatment with protocol modification, administered by
physician or other qualified health care professional, face–to–face
with multiple patients, ea 15 mn |
|
0362T |
Behavior identification supporting assessment, ea 15 mn of techs 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 2+ techs; for a patient who exhibits
destructive behavior; completion in an environment that is customized to
the patient`s behavior |
|
0373T |
Adaptive behavior treatment with protocol modification, ea 15 mn of
techs 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 2+ techs; for a patient who exhibits
destructive behavior; completion in an environment that is customized to
the patient`s behavior |