Prior Authorization Required

Prior authorization is required for outpatient ABA therapy. All requests (initial and continuation) must be submitted using the designated FEP Prior Approval Form and include the ABA treatment assessment. Approval is specific to ABA services and does not guarantee coverage of unrelated therapies.

• Use the FEP Prior Approval Form for all outpatient ABA prior approval requests.
• Authorizations apply only to ABA therapy and do not include occupational, speech, physical, educational, or other services.

Prior Authorization — Medical Necessity & Clinical-Effectiveness

Prior authorization determinations require demonstration of medical necessity based on clinical-effectiveness justification. Requests must show anticipated clinically meaningful, functional improvements tied to individualized treatment goals.

• Medical necessity review of progress will occur every 6 months (or sooner if warranted); continuation requests must document ongoing benefit.
• If insufficient improvement is demonstrated across successive authorizations, coverage may be reduced or denied.

BCBA Oversight and Written Plan Required

Prior authorization requests must be overseen by a BCBA or BCBA-D. The BCBA is responsible for assessment, development and supervision of behavior analytic interventions, and documentation of onsite supervision.

• BCBA/BCBA‑D must submit and sign treatment plans and supervision documentation.
• Undergraduate-level behavior analysts must be supervised by BCBA/BCBA‑D; RBTs and technicians must be supervised per BCBA direction.

Required Documentation for Requests

Required documentation must accompany all initial and continued prior authorization requests. The BCBA must submit a complete medical record including standardized and non-standardized assessments, data, and treatment planning materials.

• Preferred assessments: ABLLS, VB‑MAPP, or other developmentally appropriate instruments.
• Functional Behavior Assessment with operational definitions and data collection plan.
• Individualized treatment plan with measurable goals (expected to be reasonably achievable within six months) including baseline, mastery criteria, estimated date of mastery, and generalization plan.
• Documentation of treatment participants, procedures, setting, and onsite supervision notes.

Required Documentation Elements

Prior approval submissions should include specific supporting documentation elements: graphs and celebration charts, progress notes linking interventions to goals, ABLLS/VB‑MAPP or equivalent assessments, caregiver training curriculum, and a written transition/discharge plan.

• Progress data (graphs) demonstrating response to interventions and linkage to targeted goals.
• Parent/caregiver training plans with measurable caregiver skill acquisition goals and monitoring.
• Written transition and aftercare planning, with roles/responsibilities and timeline for step‑down.

Outcome Measurement & Evidence Justification

When requesting or continuing ABA services, providers should explicitly justify the selection of interventions and expected outcomes using a study-selection and outcome‑measurement approach. Documentation should specify prespecified, clinically meaningful improvement thresholds.

• Describe comparator(s) considered (e.g., standard clinical care, educational, pharmacologic, psychological) when applicable.
• Identify outcome measures to be used and the prespecified improvement thresholds that will indicate clinical benefit.

Prior Authorization and Coding

Coding must be accurate on all prior authorization requests and claims. Use the listed CPT and tracking codes for ABA services and include supporting documentation linking billed codes to the supervised treatment plan and progress data.

• Document services using CPT codes 97151–97158 and tracking codes 0362T, 0373T as appropriate.
• Include applicable HCPCS, Revenue, Place of Service, and ICD‑10 diagnosis codes. Incorrect coding may trigger denials.

Telehealth Limitations

Telehealth is not an approved delivery method for direct ABA services. Limited use of telehealth/telemedicine is permitted for parent education (e.g., 97156, 97157) and for remote supervision activities (e.g., 97155) only if the member's benefit plan allows telehealth services; it is recommended telehealth be combined with face‑to‑face supervision.

• Direct ABA (treatment delivery) via telehealth is not approved.
• Telehealth may be used for caregiver guidance and some supervision if allowed by the member's plan and documented in the authorization.

Comparator Consideration & Evidence Limitations

Comparators and evidence limitations should be considered in authorization decisions. The current evidence base has limited long‑term and high‑quality controlled studies, which constrains broad coverage conclusions and requires individualized justification.

• Comparators include behavioral, developmental, educational, pharmacological, psychological, and complementary/alternative approaches.
• Document the rationale for selecting ABA relative to available comparators and cite relevant evidence where possible.

Risk of Denial for Lack of Progress

Risk of denial increases if expected progress is not documented. If the member does not demonstrate clinically meaningful improvement or progress toward goals across successive authorization periods, benefit coverage may be reduced or terminated.

• Continued authorization requires submitted data demonstrating significant functional progress linked to treatment goals.
• Lack of documented generalization to caregivers or natural settings, or missing discharge/transition planning, increases likelihood of denial.