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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 10/01/2011 Title: Applied Behavior Analysis Treatment of Autism
Revision Date: 12/01/2018 Document: BI322:00
CPT Code(s): H0031, H0032, H2012, H2019, 0359T-0374T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Pursuant to Arkansas State law, Applied Behavior Analysis (ABA) will be covered subject to the criteria below:

1)    ABA treatment must be ordered for a specific individual diagnosed with autism by a licensed physician or clinical psychologist.

2)    ABA requires that a treatment plan be preauthorized by QualChoice. The treatment plan criteria must:

                      i.        Be developed by a Board Certified Applied Behavior Analyst during a face-to-face evaluation of the patient,

                    ii.        Specify the objective behaviors that are being targeted for improvement,

                   iii.        Indicate the time frame for improvement and the method of measuring improvement, and

3)    Be resubmitted periodically (as with any therapy) based on the individualized preauthorization interval.  The updated treatment plan should include goals and documented benefits of interventions.  Preauthorization for further treatments will be based on the information provided in the periodic re-evaluation. ABA must be provided or supervised by a Board Certified Applied Behavior Analyst.

4)    It is recommended that ABA be initiated between the ages of 2 and 5 years old (preschool age).  It is not covered above 18 years of age.

5)    Use of Telemedicine for providing ABA is not covered.


Medical Statement

1)    Applied behavior analysis (ABA) may be covered for members two years of age to under 19 years of age, subject to documentation of the following criteria:

A)   There has been an established DSM-IV diagnosis of a Pervasive Developmental Disorder (F84.0 – F84.9); AND

B)     ABA treatment is ordered for a specific individual by a licensed physician or clinical psychologist; AND

C)     The treatment is provided by or supervised by a board certified Applied Behavioral Analyst; AND

D)     There is documentation of severe behavior that:

(i)      Presents a health or safety risk to self or others; OR

(ii)    Significantly interferes with home or community activities; AND

E)     Less intensive behavior treatment has been unsuccessful in managing or treating the behaviors; AND

F)     There has been established a reasonable expectation on the part of the therapist that the ABA treatment will significantly improve the behaviors; AND

G)     The treatment plan is built on individual and objectively measurable goals; AND

H)     Caregiver training and support is a part of the treatment plan; AND

I)       The number of service hours necessary to address the behaviors is listed in the treatment plan; AND

J)      The treatment plan is approved by QualChoice.

2)    An updated treatment plan must be resubmitted periodically (as with any therapy) based on the individualized preauthorization interval.  The updated treatment plan should include goals and documented benefits of interventions.  Preauthorization for further treatments will be based on the information provided in the periodic re-evaluation.

3)    Continuation of treatment is dependent on documented evidence of progress in objective evaluations.

4)    ABA should be utilized for a minimum of 15 hours per week, and not to exceed 30 (thirty) hours per week between the ages of 2 and 6 (less than 7) and less than 10 hours per week between the ages of 7 and 18 (less than 19).

5)    There is currently no research supporting benefits of continuing ABA for more than two (2) years.

Codes Used In This BI:

H0031

Mental Health assessment by non-physician

H0032 

Mental Health service plan development by non-physician

H2012

Behavioral health day treatment per hour

H2019

Therapeutic behavioral services, per 15 minutes

0359T 

Behavior identification assessment, face to face, including testing

0360T  

Observational behavioral follow up assessment, first 30 minutes

0361T  

          ea addt’l 30 min

0362T 

Exposure behavioral follow up assessment, first 30 minutes

0363T  

          ea addt’l 30 min

0364T

Adaptive behavior trtmt by protocol, admin by tech, face-to-face w/1 patient; 1st 30 mn of tech time

0365T

          ea addt’l 30 mn of tech time

0366T 

Group adaptive behavior treatment by protocol, first 30 minutes

0367T 

          ea addt’l 30 min

0368T 

Adaptive behavior treatment with protocol mod, first 30 minutes

0369T 

          ea addt’l 30 min

0370T  

Family adaptive behavior treatment without patient present

0371T

Multiple family group adaptive behavior treatment

0372T  

Adaptive behavior treatment social skills group

0373T  

Exposure adaptive behavior treatment requiring two or more technicians

0374T  

          ea addt’l 30 min


Limits

1)    ABA treatment is not effective for:

a)    Speech

b)    Occupational therapy

c)    Supportive respite care

d)    Recreational therapy

e)    Orientation and mobility

2)    ABA treatment should end when:

a)    There has been no meaningful improvement in the patient’s behavior after a significant period of treatment; OR

b)    The treatment is making the behaviors worse; OR

c)    The patient has achieved adequate stabilization whereby less intense services  are appropriate; OR

d)    The treatment has demonstrated the inability to maintain long term gains; OR

e)    The member is 19 years of age or older.

 

3)    Will never cover beyond 2 years because of lack of research evidence supporting ABA treatment.

4)    Group treatments involving multiple patients (0366T, 0367T, 0371T and 0372T) are not covered.  Autism spectrum disorders are highly variable and therefore require highly individualized interventions that cannot be effectively provided in a group.   

5)    Family adaptive behavior treatment without patient present (0370T) is not covered as the benefit of this has not been proven in research.


Background

Autism spectrum disorder (ASD) is a complex, pervasive developmental disability characterized by variable social and communicative deficits with repetitive, restricted behaviors and for many, significant cognitive impairment. The Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision (DSM-IV-TR) specifies autistic disorder, pervasive developmental disorder---not otherwise specified (PDD-NOS), and Asperger’s syndrome as included under the diagnosis of ASD. The Center for Disease Control (CDC) estimates the prevalence of ASD as 1 out of every 110 children occurring in all ethnic, racial, and socioeconomic groups but 4-5 times more likely in boys than girls. A CDC report published in 2009, demonstrated that an average of 41% of ASD individuals met a definition of intellectual disability.

Early intensive behavioral intervention (EIBI) is a therapy based on applied behavioral analysis (ABA) proposed as an effective intervention for children with ASD. Several discipline-specific intensive intervention programs utilizing ABA have been developed and advocated for the treatment of autism (Lovaas therapy, Early Start Denver Model, and others).  These programs involve highly structured techniques delivered by a therapist on a one-to-one basis 15-30 hours per week for a period of up to 2 years.  The goals of this treatment are to improve communication, social interaction, and adaptive behavior. The American Academy of Pediatrics released clinical reports in 2007 dealing with both the diagnosis of ASD and its management. The educational interventions mentioned included both behavioral and Habilitative strategies concentrating on the development of communication skills, socialization skills, adaptive skills, and control or ablation of disruptive behaviors. The authors note that early childhood educational programs are built on several models, including behavior analysis, developmental, or structured teaching.  Recommendations for such programs included the following:

-        Children should be entered in an early childhood educational program as soon as there is serious consideration of ASD as a diagnosis;

-        The intervention should be highly structured and intensive, with child actively involved at least 25 hours per week for 12 months per year;

-        The student-to-teacher ratio should be low enough to allow “sufficient” amounts of 1:1 time and small group instruction;

-        A family component should be included;

-        Opportunities to interact with typically developing peers should be provided;

-        There should be ongoing measurement of the child’s progress and changes in approach when indicated; and

-        The domains of communication, social skills, functional adaptive behavioral skills, cognitive skills, and traditional readiness and academic skills, as developmentally indicate.

A total of fifteen studies were included for review (3 randomized, controlled trials (RCT) and 12 non-randomized, comparative studies) that met selection criteria.  In one of the RCT’s (Sallows and Graupner, 2005), children in both the experimental and control groups improved significantly over time, but there was no statistically significant difference between groups.  Another RTC (Smith, 2000), found a significantly better cognitive and communication skills in the experimental group but no difference in adaptive skills. A more comprehensive and better constructed study, the Early Start Denver Model (Dawson et al, 2009) found significant improvement in IQ, language, and adaptive behavior in toddlers (18 to 30 months) who received 20 hours per week of therapy for 2 years compared to a control group of children who received community available therapy.  Diagnostic assignment also improved significantly in the experimental group (29% improved from autistic disorder to PDD), but no significant change in ADOS severity scores.

The non-randomized, comparative studies include the seminal study by Lovaas et al (1987; McEachin, 1993).  While these original studies involved a clinic-based ABA therapy program, other studies have compared home-based, community-based, school-based, residential, and outpatient programs.  All of the studies were small, involved children between 15 months to 7 years of age, and utilized IBI at a high level (Lovaas, 40 hours/week of in center, therapist let treatment).  They reported significant improvement in 47% of children with subsequent follow-up (McEachin, 1993) durable improvement sustained for 5 years. This study had a number of serious flaws: small sample size (n=59), no randomization, selection bias (exclusion of low-functioning autistic children), non-standard endpoints focus on IQ and school placement overlooked other important social and behavioral impairments, and important differences in male: female ratios.  In addition, review has suggested that a select subgroup of children were responsible for the overall changes in the intervention group: the 9 individuals described as “normal functioning” after treatment had a mean IQ gain of 37 points compared to the other 10 members of the intervention group who had a mean gain of only 3 points.  Others note that this degree of improvement has not been replicated in any other subsequent study. Overall this research has been criticized for producing unrealistic expectations about the ability of EIBI to help ASD children attain normal developmental status.

In 2004, Shea noted that the results of these early studies have been misstated and misinterpreted by advocates of EIBI and called upon professionals to acknowledge that while EIBI may be beneficial in some ASD individuals, there is no evidence to point to “recovery” or cure. A systematic review by Bassett et al (2000) concluded that while many forms of EIBI benefit ASD, “there is insufficient, scientifically-valid effectiveness evidence to establish a causal relationship between a particular program of intensive, behavioral treatment, and the achievement of ‘normal functioning’.”

Less intensive interventions focusing on providing parent training for bolstering social communication skills and managing challenging behaviors have been associated in individual studies with short-term gains in social communication and language use.  The current evidence base for such treatment remains insufficient, with current research lacking consistency in interventions and outcomes assessed.

Although all of the studies of social skills interventions reported some positive results, most have not included objective observations of the extent to which improvements in social skills generalize and are maintained within everyday peer interactions.  Strength of evidence is insufficient to assess effects of social skills training on core autism outcomes for older children or play-and interaction-based approaches for younger children.

A Cochrane review in 2012 found that there is some evidence that EIBI is an effective behavioral treatment for some children, but that the lack of randomized trials limits the current state of evidence.  Similarly, the Agency for Healthcare Research and Quality published an evaluation of therapies for children with autism spectrum disorder in 2011 and concluded that the lack of consistent data limits the ability to determine whether interventions result in clinically meaningful changes in functioning.

 

An updated, systematic review of the most current evidence by AHRQ in 2014 supports early (2-6 yrs of age), intensive (15-30 hrs. /wk.) ABA therapy for up to 2 years duration.  At this time the evidence does not support ABA therapy below 2 years of age or for patients 13 and older.  Between 7 and 12 years of age (school age) the efficacy is less dramatic and appears to be achieved with interventions of shorter duration and lesser intensity.  Patients in the studies and responses noted were highly heterogeneous.

In summary, as the body of research on which to base conclusions grows, evidence appears to increasingly support early, intensive EIBI for ASD in preschool children. The benefits of EIBI for ASD appear less dramatic once in school and the evidence does not support EIBI younger than 2 or 13 years of age and older.   


Reference

1)      Agency for Healthcare Research and Quality (AHRQ). (2011) Therapies for children with autism spectrum disorders: a review of the research for parents and caregivers. AHRQ Pub. No. 11-EHC029-A. June 2011.

2)      Agency for Healthcare research and Quality (AHRQ). (2014) Therapies for children with autism spectrum disorder: Behavioral interventions update. AHRQ Pub. No. 14-EHC036-EF. August 2014.

3)      Bassett K, Green CJ, Kazanjian A. (2000) Autism and Lovaas treatment: A Systematic review of effectiveness evidence. Prepared for the British Columbia Office of Health Technology Assessment, Vancouver, Canada. .Retrieved 27 July 2008 from chspr.ubc.ca.

4)      Dawson G, Rogers S, Munson J, et al. (2010) Randomized, controlled trial of an Intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010; 125(1):e17-e23.

5)      Lovaas OI. (1987) Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol.1987; 55(1):3-9.

6)      McEachin JJ, Smith T, Lovaas Ol. (1993) Long-term outcome for children with autism who received early intensive behavioral treatment. Am J Ment Retard. 1993; 97(4):359-391.Myers, SM, Johnson CP. (2007) Management of children with autism spectrum disorders. Pediatrics. 2007; 120(5):1162-1182.

7)      Rice C. (2006) Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm

8)         Reichow B, Barton EE, Boyed BA, et al. (2012) early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012 Oct 17; 10:CD009260.

9)         Sallows GO, Graupner TD. (2005) Intensive behavioral treatment for children with Autism: four-year outcome and predictors. Am J Ment Retard, 2005; 110(6):417-438.

10)      Shea V. (2004) A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism, 2004; 8(4):349-367.

11)     The American Psychiatric Assoc. (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Publishing; 2000.

12)     Warren Z, Veenstra-VanderWeele J, Stone W, et al. (2011) Effective Health Care. Therapies for Children with Autism Spectrum Disorders. Executive Summary. Comparative Effectiveness Review No. 26. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.