Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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: 04/01/2019 Document: BI322:00
CPT Code(s): 0362T, 0373T, 97151-97158
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.

Applied Behavioral Analysis (ABA) is the application of behavioral principles to everyday situations, intended to increase or decrease targeted behaviors. ABA has been used to improve areas such as language, self-help, and play skills, as well as decrease behaviors such as aggression, self-stimulatory behaviors, and self-injury. For those with autism spectrum disorder (ASD), treatment may vary in terms of intensity and duration, complexity and treatment goals, and the extent of treatment provided characterized as focused or comprehensive. Focused ABA is direct care provided for a limited number of behavioral targets. It is appropriate for those who need treatment only for a limited number of key functional skills or have such acute problem behavior that its treatment should be the priority. Comprehensive ABA is for treatment of multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. It ranges from 25 – 40 hours of treatment per week (plus direct and indirect supervision and caregiver training) to increase the potential for behavior improvement. ABA can also be referred to as Lovaas therapy and intensive behavioral intervention (IBI).  

 

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 and evidence supporting continued benefit. ABA must be provided or supervised by a Board Certified Applied Behavior Analyst.

4)    ABA is not covered above 18 years of age.

5)    ABA is not covered when provided in a school or via telemedicine.


Medical Statement

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


Limits

ABA is not for the purpose of any of the following:

1)    Speech therapy;

2)    Occupational therapy;

3)    Vocational rehabilitation;

4)    Supportive respite care;

5)    Recreational therapy;

6)    Orientation and mobility;

7)    ABA services provided in the school setting.

8)    ABA services provided via telemedicine.


Background

A number of scientific studies have been conducted evaluating the effectiveness of ABA. The original and long–term follow–up study conducted by O. Ivar Lovaas included 38 children who were non–randomly assigned to ABA therapy or minimal therapy.  Outcomes were compared to data from 21 children in another facility that had similar characteristics. Lovaas reported improvements in cognitive function and behavior that were sustained for at least 5 years. Almost half of the ABA group passed normal first grade and had an IQ score that was at least average. The flaws in this study included: small sample size, non–randomization of patients to treatment groups, potential selection bias, and endpoints that may not meet current standards (Hayes Medical Directory). More recent studies have reported effectiveness in some autistic children, especially in relatively high–functioning children, but none have replicated the results from the Lovaas study.

Multiple systematic reviews with meta–analyses have been conducted on ABA studies for ASD, with conflicting results. Ospina and colleagues (2008) systematically reviewed studies comparing behavioral and developmental interventions for ASD. The four randomized control trials (RCTs) reviewed that compared ABA to Developmental Individual–difference relationship-based intervention (DIR) or Integrative/Discrete trial combined with Treatment and Education of Autistic and related Communication Handicapped Children (TEACCH) found no significant difference in outcomes (Ospina et al., p. 4). Seven out of eight studies that reported significant improvements were not RCTs and have significant methodological limitations (Ospina et al., 2008, p. 5). Results from a meta–analysis of controlled clinical trials demonstrated that Lovaas is superior to special education for a variety of outcomes; however, there is no definitive evidence suggesting superiority of Lovaas over other active interventions (Ospina et al. 2008, p. 26). Additionally, five other systematic reviews found that ABA was an effective intervention for ASD, but still noted the substantial limitations of included studies, which could affect meta–analysis results and the expected efficacy of ABA (Eldevik 2009; Reichow 2009; Makrygianni 2010; Virues–Ortega 2010; Warren et al. 2011).

Furthermore, Reichow and others (2014) conducted a systematic review of the RCTs, quasi–RCTs, and controlled clinical trials in the ABA literature, commenting that these were not of optimal design. Reichow and others (2014) concluded that the evidence suggests ABA can lead to improvements in IQ, adaptive behavior, socialization, communication and daily living skills. However, they strongly caution that given the limited amount of reliable evidence, decisions about using ABA as an intervention for ASD should be made on a case by case basis (Reichow et al. 2014, p. 33). In contrast, Spreckley and Boyd (2009) state in their systematic review that children receiving high intensity ABA did not show significant improvement in cognitive functioning (IQ), receptive and expressive language, and adaptive behavior compared to lesser interventions including parenting training, parent–applied behavior intervention supervised weekly by a therapist, or interventions in the kindergarten.

Further research needs to be done to determine the effectiveness of ABA at improving IQ, language skills, social skills, and adaptive behaviors, especially compared to other interventions. In addition, rigorous studies should examine which subgroups of children or adolescents with ASD benefit the most from ABA.

Coding Implications:

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all–inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up–to–date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.


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.