Governs coverage and medical necessity criteria for Adaptive Behavioral Treatment (including ABA/IBI) for individuals with Autism Spectrum Disorder when a California state mandate or specific benefit provides coverage; applies to commercial members of Anthem Blue Cross in California.
Key ActionSubmit diagnosis and a person-centered ABT treatment plan with measurable goals and standardized baseline assessments when requesting prior authorization.
No material clinical or coverage changes in this revision.
40Max direct ABT/week
20Assessment hours (max without rationale)
20-40Comprehensive intensity (guideline)
6 monthsTreatment plan update interval
Not covered except ASDCoverage stance for non‑ASD
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11/09/2023Most recent review
Coverage and Medical Necessity Criteria
Initial Assessment and Planning
Covered when ALL of the following are met
Assessment and Planning selection criteria: A diagnosis of ASD has been made by a licensed medical professional or other qualified health care professional consistent with state licensing requirements; and documentation of a person-centered treatment plan that: addresses identified behavioral, psychological, family, and medical concerns; includes objective, measurable goals based on standardized assessments with baseline measures, progress-to-date, and anticipated timelines; documents that ABT services will be delivered by appropriately licensed or certified providers; includes completed assessments of motor, language, social, and adaptive functions; and incorporates age-appropriate goals with anticipated timelines, family education/training, estimated dates of mastery, plans for generalization, and discharge/transition planning.
From Clinical Indications: Assessment and Planning.
Behavior Identification Assessments
Covered when ALL of the following are met
Behavior identification assessment: Required prior to beginning a course of ABT and must include use of a standardized assessment (e.g., VB-MAPP, Vineland, ADOS).
Behavior identification assessment is prerequisite.
Behavior identification supporting assessment formats: Either: (a) behavior identification supporting assessment performed by one technician under the direction of a physician/qualified professional when one or more non-redirectable disruptive behaviors are present (request must describe the disruptive behavior(s)); OR (b) assessment performed with a physician/qualified professional present on site with assistance of two or more technicians when non-redirectable disruptive behaviors pose significant risk of harm (request must describe behaviors, exposure plan, and safety/conduct setting).Assessment time together up to 20 hours; >20 hours requires rationale
Details on staffing, documentation, and repeat assessment frequency provided.
Adaptive Behavioral Treatment — Individual and Protocol Modification
Adaptive behavior treatment by protocol may be covered when ALL of the following are met
General ABT by protocol: Individual meets initial or continuing treatment criteria; person-centered treatment plan in place; treatment delivered by a certified/licensed physician, qualified provider, or ABT technician in accordance with state law and benefit plan requirements; total direct ABT is 40 hours per week or less (requests >40 hours require justification); protocol modification provided by a certified/licensed professional; hours requested are justified by number of behavioral targets and key functional skills.<=40 hours/week
Documentation required if >40 hours planned.
ABT with protocol modification staffing (one technician): When delivered with a physician or qualified professional present and up to one technician: the person-centered plan details type, severity, and frequency of non-redirectable disruptive behaviors; specifies services and key functional skills; is administered by licensed/certified provider with no more than one technician present; requested hours are included in the total ABT hours.
From criteria for protocol modification (single technician).
Group and Family Adaptive Behavior Treatment
Group and family interventions may be covered when ALL of the following are met
Group adaptive behavior treatment: Person-centered treatment plan addresses specific treatment goals and targeted problem areas; goal is to train a group to reduce maladaptive behaviors and increase skill acquisition or social interactions; session conducted by a certified/licensed physician, qualified provider, or ABT technician; individual has sufficient social, language, and adaptive skills to participate; hours are justified and included in the 40 hours/week total.<=40 hours/week total
Group sessions included in weekly maximum and must be justified per behavioral targets.
Family adaptive behavior treatment guidance: Goal is to instruct parent/guardian/caregiver in treatment protocols to reduce maladaptive behaviors and increase generalization of skills; person-centered plan addresses targeted behaviors and specific goals; guidance may be performed with or without the affected individual present.
Multiple-family group guidance requires shared behavioral targets and is performed without the affected individual present.
Continuation of Treatment
Continuation of ABT may be covered when ALL of the following are met
Continuation criteria: Individual continues to meet initial criteria for ABT; updated person-centered treatment plan submitted generally every 6 months (or more often if required); plan includes age- and impairment-appropriate goals and measures of progress (social, communication, language, adaptive functioning, and targeted behaviors); interim progress assessments at least every 6 months and standardized developmental assessments no less frequent than every 2 years; for each goal document progress-to-date relative to baseline, anticipated timeline, family education/training, estimated mastery date, plan for generalization, and transition/fade/discharge planning.Interim assessments >= every 6 months; standardized assessments >= every 2 years
Hours up to 40/week can continue but should be reviewed and adjusted per assessments.
Initial and continued ABT coverage criteria
Covered when ALL of the following are met
Diagnosis: Confirmed diagnosis of Autism Spectrum Disorder by a licensed medical professional, licensed psychologist, or other qualified health care professional.
From Diagnostic criteria and requirement for confirmation prior to ABT initiation.
Person-centered plan: A person-centered treatment plan addressing behavioral, psychological, family, and medical needs with measurable, objective goals based on standardized assessments (e.g., VB-MAPP, Vineland) and a plan for measuring progress.
Use of standardized assessments and measurable goals required.
Baseline assessment: Baseline evaluation of motor, language, social, adaptive, and cognitive functions prior to initiation of ABT; use of standardized assessments and periodic re-assessment with treatment plan updates generally every 6 months and standardized assessments at least every 2 years.
Assessment of baseline domains required to inform treatment.
Adaptive Behavioral Treatment (ABT) is considered not medically necessary for all diagnoses other than Autism Spectrum Disorder (ASD). To the extent a state mandate or specific benefit permits ABT to be reviewed using clinical criteria, ABT is not covered when the policy's stated clinical criteria are not met or when required documentation of progress is absent.
ABT is not covered / considered not medically necessary for diagnoses other than those listed (non‑ASD indications). The policy notes there is no published literature demonstrating benefit of ABT for conditions other than ASD and no clinical practice guidelines recommending ABT for non‑ASD indications.
Services that are primarily educational in nature may be excluded from coverage by benefit contracts. When an intervention is intended mainly to teach academic knowledge, communication methods, or school‑based curricula, applicable contract exclusions for educational services should be applied.
Historical note: Section IV was revised on 11/05/2020 to add the statement that ABT is not medically necessary for indications other than ASD. This revision was part of MPTAC review and is documented in the policy's revision history.
When the coverage criteria are not met or when there is no documentation of clinically significant progress on interim standardized assessments, ABT will be considered not covered and not medically necessary. Required domains for interim progress evaluation include adaptive functioning, communication, language, and social skills, and lack of meaningful improvement on these standardized measures supports denial.
Services that do not meet the documented clinical criteria, lack measurable benefit on accepted standardized assessments, or are provided for non‑ASD diagnoses are considered not medically necessary. The policy specifically states the benefit of ABT has not been demonstrated outside of ASD and that absence of measurable developmental progress on validated tools does not support continued use.
Prior policy revision note: On 11/05/2020 the policy was revised to add the statement that ABT is considered not medically necessary for indications other than Autism Spectrum Disorder; this change is recorded in the document's revision history.
Coding and Visit Limits
Covered/Applicable Codes (examples)mixed
97151
Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes 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 one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
97153
Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes.
97154
Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
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 one patient, each 15 minutes.
97156
Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157
Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158
Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.
0362T
Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the physician or other qualified health care professional on site; with the assistance of two or more technicians; 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, each 15 minutes of technicians’ time face-to-face with a patient, requiring the physician or other qualified health care professional on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
1–10 of 19
1/2
Diagnosis Codes referencedICD-10
F84.0
Autistic disorder.
F84.3
Other childhood disintegrative disorder.
F84.5
Asperger's syndrome.
F84.8
Other pervasive developmental disorders.
F84.9
Pervasive developmental disorder, unspecified.
Coding history/notesmixed
No codes listed
Behavior identification assessment time — Up to 20 hours combined in initial or repeat assessment without additional rationale
Assessment time capBehavior identification assessment and supporting assessment together comprise up to 20 hours of evaluation time; >20 hours requires rationale with the request.
Repeat assessment intervalRepeat behavior identification assessment when indicated by periodic standardized measurements; repeat assessments should be fewer than 20 hours in a 6‑month interval; >20 hours should trigger an updated treatment and progress report.
Required componentsEach request for ABT must include an assessment using a standardized tool (e.g., VB‑MAPP, Vineland, ADOS).
Direct ABT weekly hours — <= 40 hours per week (generally); protocol modification total <= 8 hours/week when indicated
Maximum weekly direct ABT
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization
Prior Authorization and Limits
Prior authorization requires submission of the confirmed diagnosis and the person-centered ABT treatment plan that meets the selection criteria. Plans that adopt these Clinical UM Guidelines may require prior authorization; whether prior authorization is required depends on the plan or line of business. To determine if review or prior authorization is required for this guideline, contact the customer service number on the member's ID card.
Prior authorization requests must include the diagnosis of ASD by a licensed or otherwise qualified health care professional as consistent with state licensing requirements.
Requests must include the person-centered treatment plan with measurable goals, baseline measurements, anticipated timeline for achievement, and documentation of who will deliver services (licensed/certified provider or qualified technician).
If requesting >20 hours of behavior identification assessments or >40 hours/week of direct ABT, provide a clinical justification.
Documentation Required
Assessment and Plan Required Before Treatment
Level of Care and Service Settings
Eligibility and Program Operational Criteria for ABA/IBI
ABA/IBI Eligibility
ABA/IBI (ABT) criteria
ABA/IBI eligibility: Diagnosis of ASD by a licensed/qualified professional; required standardized assessments; and a person-centered treatment plan with measurable goals, family training, and documentation of provider qualifications.
Individual ABT by protocol: Delivered by a certified/licensed physician, qualified healthcare provider, or ABT technician (in accordance with state law and benefit plan requirements), up to 40 hours/week; goals and hours justified in the treatment plan.<=40 hours/week
Group ABT: Participant must have sufficient social, language, and adaptive skills to participate; group goals and hours are included in the weekly maximum of direct ABT hours.Included in 40 hours/week total
Family guidance: Training for caregivers to implement protocols to reduce maladaptive behaviors and generalize skills; may be delivered with or without the individual present; multiple-family groups require shared behavioral targets and are performed without the individual present.
Session Frequency, Intensity, and Supervision Limits
Direct ABT treatment hours (maximum without additional justification) — 40
Direct ABT treatment hours (max)40 hours per week (maximum without additional justification)
Documentation for excess hoursRequests for more than 40 hours/week must include documentation explaining why additional hours are planned.
Included servicesTotal hours should reflect behavioral targets, services, and key functional skills to be addressed with a clinical summary justifying hours requested.
Protocol modification hours (typical maximum when delivered with higher staffing for destructive behaviors) — 8
Typical maximum for protocol modification8 hours per week (typical maximum when delivered with higher staffing for destructive behaviors)
Staffing context
Key Definitions
ABT — Adaptive Behavioral Treatment defined (umbrella term including ABA, IBI)
DefinitionAdaptive Behavioral Treatment (ABT) is used in this document as an umbrella term that includes services such as Applied Behavioral Analysis (ABA) and Intensive Behavioral Intervention (IBI).
Intervention basisABT applies learning theory and behavioral/developmental interventions to improve socially significant behaviors and demonstrate intervention effect.
Supervision modelABT is typically implemented by multiple individuals under a treatment plan created and supervised by a licensed or certified behavioral analyst or qualified professional.
ASD — Autism Spectrum Disorder definition (DSM-5)
DSM‑5 definitionAutism Spectrum Disorder (ASD) is defined per DSM‑5 as a spectrum encompassing previously separate disorders (eg, Asperger's, childhood autism, PDD‑NOS) characterized by persistent deficits in social communication and restricted/repetitive behaviors.
Background and Evidence Summary
Background: Adaptive Behavioral Treatment (ABT), including Applied Behavior Analysis (ABA) and Intensive Behavioral Intervention (IBI), is used to treat individuals with Autism Spectrum Disorder. Diagnosis of ASD is often complex and should follow established evaluation recommendations; baseline and periodic standardized assessments (for example, Vineland, VB‑MAPP, ADOS) are used to define baseline functioning and to document progress over time.
Key ActionSubmit diagnosis and a person-centered ABT treatment plan with measurable goals and standardized baseline assessments when requesting prior authorization.
ABT with protocol modification for destructive behaviors (two or more technicians):
When non-redirectable destructive behaviors pose significant risk of harm, ABT with protocol modification may be provided with a physician/qualified professional present and two or more technicians; request must describe the behaviors posing risk, the plan to expose the individual to relevant stimuli, and how the assessment/treatment will be conducted in a setting conducive to safety for the individual and others; total protocol modification hours generally 8 hours or less per week unless additional rationale is provided.
<=8 hours/week for protocol modification
Staffing and environment requirements specified.
Intensity appropriate to need: Treatment intensity consistent with guidelines: comprehensive ABT generally 20–40 hours/week and focused treatments 10–25 hours/week, tailored to individual needs and goals; total direct ABT generally limited to 40 hours/week without additional justification.20-40 hours/week (comprehensive); 10-25 hours/week (focused)
Supported by BACB and HRSA guideline references.
Supervision: Regular direct supervision by a licensed or certified provider with the recommended supervision ratio of approximately 2 hours of supervision per 10 hours of direct treatment.2:10 supervision ratio
BACB supervision standard.
Evidence of benefit: Continuation of ABT requires documented measurable benefit on standardized assessments; absence of clinically significant developmental progress on standardized interim assessments does not support continued treatment.
Continuation contingent on documented measurable benefit.
Total direct ABT treatment should be 40 hours per week or less; documentation required for plans >40 hours/week.
Protocol modification allocationUp to 2 hours of protocol modification are covered for every 10 hours of direct ABT (typical allocation).
Protocol modification weekly capTotal hours of adaptive behavior treatment with protocol modification generally should be 8 hours or less per week; >8 hours requires rationale.
A thorough assessment and a documented person-centered treatment plan are required before initiating ABT. The assessment must confirm the ASD diagnosis and provide baseline evaluation of motor, language, social, adaptive (and when indicated cognitive) functioning. Standardized assessments should be used before starting treatment and at regular intervals thereafter to measure progress.
Behavior identification assessment (standardized tool such as VB-MAPP, Vineland, ADOS) is required prior to beginning ABT.
Assessments of motor, language, social, and adaptive functions must be completed and documented prior to treatment initiation.
Use standardized assessments for baseline and interim progress measures; examples include VB-MAPP and Vineland.
Note
Prior Authorization Depends on Plan Adoption
Clinical UM Guidelines are available for plans to adopt for utilization review of medical necessity. Adoption is optional and may vary by plan, line of business, or state mandate. Federal and state law, contract language, and Medical Policy take precedence over these guidelines.
Whether prior authorization or guideline-based review applies depends on the plan/line of business and any applicable state mandates.
Plans may use the guideline for provider education or selective claims review even if they do not adopt it universally.
Contact the member's customer service number to determine whether this guideline is used for utilization review for a specific member/plan.
Denial Risk
Denial Triggers
Requests that lack required documentation, do not meet the stated selection criteria, or lack documented clinically significant progress on standardized interim assessments are at risk for denial. ABT is not medically necessary for diagnoses other than ASD.
Denial triggers include: missing ASD diagnosis by a qualified/licensed professional; absent person-centered treatment plan with measurable goals and baseline measures; missing standardized baseline or interim assessments.
Lack of documented clinically significant progress in adaptive functioning, communication, language, or social skills on interim standardized assessments may result in services being considered not medically necessary.
Services for diagnoses other than ASD are considered not medically necessary.
Documentation Required
Required Documentation
Providers must supply specific documentation with initial and continuation requests. Documentation must demonstrate eligibility and justify the requested services.
Diagnosis of ASD provided by a licensed medical professional, licensed psychologist, or other qualified health care professional consistent with state requirements.
Person-centered ABT treatment plan addressing behavioral, psychological, family, and medical concerns, with measurable, objective goals, baseline measures, anticipated timelines, estimated date of mastery, generalization and discharge/transition planning, and family education/training components.
Documentation of provider qualifications: who will deliver services, evidence that providers are licensed/certified per state law and benefit plan requirements, and supervision arrangements (e.g., licensed/certified provider supervision of technicians).
For continuation requests: updated person-centered treatment plan (generally every 6 months or as required by mandate) and interim progress assessments at least every 6 months; standardized assessments at least every 2 years.
Requests for protocol modification must document the licensed/certified professional performing modification and justify frequency beyond standard ratios (up to 2 hours modification per 10 hours direct therapy).
Documentation Required
Required Documentation and Assessments
Required assessments and documentation must support measurable goals and the schedule of care. Use standardized assessments for objective measurement of baseline and progress.
Treatment plan must be based on a comprehensive assessment confirming ASD diagnosis and include measurable goals tied to standardized assessment scores, baseline measures, and interim progress updates.
Behavior identification assessment using standardized tools is required prior to ABT; behavior identification supporting assessments have specific documentation requirements if disruptive or dangerous behaviors are present.
Supervision documentation: supervision by a licensed or certified professional is required; the general standard is approximately 2 hours of supervision for every 10 hours of direct treatment unless state law or plan rules specify otherwise.
When requesting therapeutic hours beyond stated guidance (e.g., >40 hours/week direct ABT or >8 hours/week for some protocol-modification scenarios), include a clinical rationale for additional time.
Note
Assessment Before Treatment
An initial behavior identification assessment is required before treatment begins; no step therapy sequence is specified. Ensure assessments identify targeted behaviors and establish baselines that inform the person-centered treatment plan.
Behavior identification assessment (standardized) must be completed and included with any initial ABT request.
If behavior identification supporting assessment is warranted due to non-redirectable or dangerous behaviors, include detailed behavior descriptions and safety planning.
Assessment time is generally expected to be up to 20 hours combined for behavior identification and supporting assessments unless additional rationale is provided.
Note
Provider Action Callout
To determine whether this guideline will be used to review services for a specific member or whether prior authorization is required, contact the customer service number on the member's ID card. Federal/state law and contract language override these guidelines.
Plans may elect to adopt these guidelines for utilization review or use them for provider education and selective review.
Customer service can confirm applicability for the member's plan or line of business.
Focused treatment definition: Focused ABT targets specific behaviors or skill deficits; typically involves 10–25 hours/week and may include group or family-oriented formats.10-25 hours/week
Chunk 30
Assessment time: Initial comprehensive assessment may comprise up to approximately 20 hours of evaluation time; repeat assessments generally fewer than 20 hours in a 6-month interval unless additional rationale provided.~20 hours initial assessment
Chunks 4,5
Supervision: Licensed or certified behavioral analyst or qualified provider must provide regular direct supervision; general standard is ~2 hours supervision per 10 hours of direct treatment.2:10 supervision ratio
Chunk 30
From Family adaptive behavior treatment guidance.
inv-42: VCA / ABA / ABT
VCA specifics: VCA uses Self-Determination Theory to promote intrinsic motivation, employing visual supports, prompting, and technology, and avoids external rewards or punishment.
Chunk 35
ABA specifics: ABA applies learning theory to improve socially significant behaviors, demonstrate intervention effect, teach new skills, and reduce interfering behaviors; supervision by licensed/certified professionals is required to oversee technicians and treatment implementation.
Chunks 29,30
May be used when physician/qualified professional is present with two or more technicians for non‑redirectable destructive behaviors posing significant risk.
Additional time rationaleIf additional protocol modification time is requested, written documentation must demonstrate need for extra time.
Comprehensive ABT intensity range — 20-40
Comprehensive ABT intensity range20–40 hours per week (recommended range for comprehensive treatment addressing multiple developmental domains)
Guideline referencesBACB and HRSA guidance support 30–40 and minimum 25 hours/week respectively; literature commonly reports 20–40 hours/week.
Scope of comprehensive treatmentTargets multiple domains: cognitive, communicative, social, emotional, adaptive functioning, and maladaptive behaviors.
Focused ABT intensity range — 10-25
Focused ABT intensity range10–25 hours per week (typical for focused treatments targeting specific behaviors or skill deficits)
Formats includedMay include group adaptive behavior treatment or family adaptive behavior treatment guidance as focused modalities.
Supervision implicationSupervision requirements (2 hours per 10 hours direct treatment) apply to ensure fidelity when delivering focused treatments.
Onset and presentationSymptoms are typically present from early childhood (often before age 3) and cause clinically significant impairment across settings.
HeterogeneityChildren with ASD vary widely in abilities, language, and behaviors; presentation ranges from nonverbal to relatively typical language with social deficits.
Core DSM‑5‑TR criteria summaryA: Persistent deficits in social communication and interaction; B: Restricted, repetitive patterns of behavior, interests, or activities (at least two features); C: Symptoms present in early development; D: Symptoms cause significant impairment; E: Not better explained by intellectual disability.
Severity levelsSpecify current severity using Levels 1–3 (Level 1 requiring support to Level 3 requiring very substantial support) based on social communication impairments and restricted/repetitive behaviors.
Associated specifiersSpecify accompanying intellectual or language impairment, associated medical/genetic conditions, related neurodevelopmental/behavioral disorders, and presence of catatonia when applicable.
Adaptive Behavior Treatment / ABA / VCA — descriptions
Applied Behavior Analysis (ABA)ABA systematically applies interventions based on principles of learning theory to improve socially significant behaviors and to demonstrate that interventions cause improvement.
Visual Communication Analysis (VCA)VCA is an application of Self‑Determination Theory emphasizing intrinsic motivation, visual supports, and avoiding external rewards or punishment.
Early Start Denver Model (ESDM) and related approachesESDM integrates ABA elements and other therapies (eg, speech, OT) targeting very young children; developmental models (eg, DIR/Floortime) focus on relationship‑based, developmental skill building.
Indexed treatment and diagnostic terms — index of terms used in document
Indexed treatment termsAdaptive Behavioral Treatment (ABT); Applied Behavioral Analysis (ABA); Early Intensive Behavior Intervention (EIBI); Early Start Denver Model (ESDM); DIR/Floortime; Intensive Behavior Intervention (IB); Lovaas Therapy; Visual Communication Analysis (VCA).
Purpose of indexLists terms used in the document to aid cross‑reference and retrieval of treatment and diagnostic terminology.
Additional resourcesWebsites and external resources for further information are provided in the document's references section.