Blue Cross Blue Shield MA ABA Coverage Update

Coverage Criteria for ABA Services

Behavior Identification Assessment (CPT 97151) - Covered when ALL are met

Covered when ALL of the following are met:

Behavior identification assessment coverage: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Assessment and treatment plan development activities are required; 3) Conducted by an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/board certified behavior analyst (BCBA) who performed both face-to-face and non-face-to-face activities.Typical course completed in 12 hours.

Behavior identification assessment includes face-to-face, standardized and non-standardized assessments and direct observations to assess skills across domains.

Behavior Identification Supporting Assessment (CPT 97152) - Covered when ALL are met

Covered when ALL of the following are met:

Supporting assessment coverage: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Administered face-to-face; 3) Completed by the behavior technician or an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/board certified behavior analyst (BCBA); 4) When more than one technician is involved, the LABA/BCBA must be on site and able to join as needed.Typical course completed in 12 hours.

Supporting assessment includes standardized and non-standardized assessments and direct behavior observations; used for significant behavioral disruption such as self-injury or intense aggression.

Multi-Technician Assessment/Treatment (0362T / 0373T) - Covered when ALL are met

Covered when ALL of the following are met:

Multi-technician services: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Administered face-to-face; 3) Appropriately trained licensed psychologist or LABA/BCBA on site and able to join treatment or assessment as needed; 4) Assistance of two or more behavior technicians; 5) Patient exhibits destructive behavior or significant behavioral disruption (e.g., self-injurious behavior, intense aggression); 6) Conducted in an environment customized to the patient's behavior.Typical course completed in 12 hours for multi-technician assessment.

Applicable CPT codes include 0362T (multi-technician assessment) and 0373T (multi-technician treatment).

Adaptive Behavior Treatment (97153/97154) - Covered when ALL are met

Covered when ALL of the following are met:

Direct treatment by protocol: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Administered face-to-face; 3) Completed by a behavior technician or an appropriately trained licensed psychologist or LABA/BCBA; 4) Implementation of individualized treatment protocols with data collection related to each treatment goal during sessions; 5) Progress on individual treatment goals is documented.Dosage individualized; comprehensive ABA typically 30-40 hours/week (up to 40 hours/week) and may include individual and group services.

Services may be one-to-one or in groups of 2–8 patients; multiple practice opportunities should be provided within sessions.

Group Adaptive Behavior Treatment with Protocol Modification and Clinician Directed Services (97158, 97155)

Covered when ALL of the following are met:

Group/protocol modification and clinician-directed services: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Administered face-to-face; 3) Completed by an appropriately trained licensed psychologist or LABA/BCBA; 4) Modifying treatment protocols and data collection related to social and/or behavioral treatment goals (97158) or providing clinical direction and/or modification of treatment procedures related to treatment goals (97155).97158 typical course: 2 hours/week for social skills group; 97155 clinical direction typical ratio: minimum 1 hour and maximum 2 hours per 10 direct hours.

Group size for 97158 is at least 2 and no more than 8 patients.

Parent/Caregiver Adaptive Behavior Treatment Guidance (97156/97157)

Covered when ALL of the following are met:

Parent/caregiver guidance: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Administered face-to-face; 3) Completed by an appropriately trained licensed psychologist or LABA/BCBA; 4) Includes modeling, observation, and guidance of caregiver implementation of treatment protocols and generalization/maintenance of treatment goals across settings.

Services may be provided to multiple family members of the same patient or to multiple families (groups of 2–8 family/caregiver groups).

General coverage criteria

Covered when services meet medical necessity and are provided by appropriately qualified clinicians and individualized per assessment

Provider qualifications and treatment planning: 1) Services provided for individuals with autism spectrum disorder and/or Down Syndrome; 2) Clinical direction provided by an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/BCBA; 3) Individualized treatment plan developed following behavioral assessment with written treatment protocols; 4) Program decisions and ongoing modifications based on direct observation, data collection, and analysis of graphed data; 5) Documentation of progress and data collection maintained in the medical record.

ABA services may be provided across community settings (home, center, daycare, preschool, camp) and should be individualized for age and severity.

The policy lists activities that are NOT covered as ABA services. Examples include providing ABA for diagnoses other than autism spectrum disorder or Down Syndrome, and non-clinical tasks such as preparation of materials, review of research, writing treatment protocols, charting data or plotting graphs. Also non-covered are services furnished to oneself or immediate family members, supervision/training of staff, and multiple LABA/BCBA providers delivering services to the same member during the same time interval.

Services billed as ABA that are provided simultaneously with other medical services are listed as non-covered examples. This includes provision of ABA at the same time as occupational therapy, speech and language therapy, physical therapy, or psychotherapy. The policy also names alternative modalities such as Relationship Development Intervention and Floor Time as non-covered when billed as ABA.

The policy clarifies that ABA should not be billed for services that are delivered concurrently with other therapies (occupational therapy, speech and language therapy, physical therapy, psychotherapy). When such services are provided simultaneously, they are considered non-covered under this ABA policy and may trigger denial if billed as ABA.

Services that do not meet the specified coverage scenarios are considered investigational or not medically necessary. Examples include services not delivered by appropriately trained/licensed personnel, services that are not face-to-face where face-to-face delivery is required (assessments and most treatment codes), or services lacking documentation of progress and data collection tied to individualized treatment goals. Services used solely for ongoing case management tasks rather than assessment or treatment planning are also not indicated.

The policy provides additional examples of non-covered services that may lead to denial. These include ABA billed for diagnoses other than autism spectrum disorder or Down Syndrome, services provided simultaneously with other medical therapies, alternative treatment modalities (e.g., Relationship Development Intervention, Floor Time), and activities that are administrative or educational in nature (preparation of materials, charting, IEP-related services). Medical records must be available on request and include session notes, treatment plans, data collection, and assessment results to support coverage determinations.

Coding and Classification

Behavior Identification AssessmentCPTCovered

97151

Behavior identification assessment

Behavior Identification Supporting Assessment / Multi-technician assessmentCPTCovered

97152	Behavior identification supporting assessment
0362T	Adaptive behavior assessment by two or more technicians with on-site LABA/BCBA present

Adaptive Behavior Treatment - DirectCPTCovered

97153	Adaptive behavior treatment by protocol
97154	Adaptive behavior treatment by protocol (additional code)
0373T	Adaptive behavior treatment by more than one behavior technician with on-site LABA/BCBA present

Group / Clinician Directed TreatmentCPTCovered

97158	Group adaptive behavior treatment with protocol modification
97155	Adaptive behavior treatment with protocol modification (clinician directed)

Parent/Caregiver GuidanceCPTCovered

97156	Parent/caregiver adaptive behavior treatment guidance
97157	Parent/caregiver adaptive behavior treatment guidance (additional code)

Covered CPT CodesCPTCovered

97151	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes
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.
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians;

Covered CPT/HCPCS Codes (specialized)CPTCovered

0362T

Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by 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.

ICD-10 Diagnosis CodesICD-10

F84.0	Autism Spectrum Disorder
Q90.0	Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1	Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2	Trisomy 21, translocation
Q90.9	Down syndrome, unspecified

inv-21: Assessment typical duration

Typical total assessment durationApproximately 12 hours to complete behavior identification or supporting assessments

Assessment componentsIncludes face-to-face standardized and non-standardized assessments and direct behavior observations across domains (social, communication, daily living, behavior)

Provider requirementConducted by an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/BCBA (face-to-face and non-face-to-face activities performed by same clinician)

inv-22: Comprehensive ABA weekly hours

Weekly hours range

Provider Actions, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization and/or precertification is required for services described in this policy. Lack of required prior authorization may result in denial of payment.

Inpatient: Precertification/preauthorization IS REQUIRED for all products when the procedure is performed inpatient.
Outpatient: Prior authorization is required for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity when performed outpatient.

Prior Authorization

Prior authorization requirements and process

Providers must submit prior authorization requests and supporting clinical documentation using Authorization Manager. Enter the facility's NPI or provider ID for the service location and the servicing provider's NPI/provider ID (not the billing group). Out-of-network requests may be faxed to 888-641-5199.

Use Authorization Manager to submit initial authorization requests, attach clinical documentation, check case status, and view decision letters.
Authorization Manager is available 24/7 and is the preferred/quickest method for requests.

Background

Applied Behavior Analysis (ABA) services are described as interventions to increase functional skills and reduce problem behaviors for individuals with autism spectrum disorder and Down Syndrome. Covered services include behavior identification assessments to develop individualized treatment plans and direct treatment delivered by behavior technicians under the direction of an appropriately trained licensed psychologist or LABA/BCBA. Parent/caregiver guidance and group or multi‑technician services are included when clinically indicated. The policy emphasizes data collection, individualized goals for skill acquisition and behavior reduction, and qualified clinical direction to ensure treatment fidelity.

Definitions and Service Descriptions

inv-36: Behavior identification assessment (CPT 97151) description

Service description (97151)Face-to-face and non-face-to-face standardized and non-standardized assessments and direct observations to assess skills across domains and develop a treatment plan

Medical necessity scenarioCovered for individuals with autism spectrum disorder and/or Down Syndrome when used for assessment and treatment plan development

Provider requirementMust be conducted by an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/BCBA who performs both face-to-face and non-face-to-face activities

inv-37: Adaptive behavior treatment by protocol (CPT 97153/97154) and with protocol modification (CPT 97155)

97153/97154 descriptionFace-to-face implementation of individualized treatment protocols by a behavior technician or LABA/BCBA with data collection related to each treatment goal

Level of Care Criteria

Outpatient / Community-based

Outpatient/community-based admission criteria: 1) Diagnosis of autism spectrum disorder and/or Down Syndrome; 2) Treatment plan developed by a qualified provider documenting medical necessity for ABA services; 3) Services appropriate to be delivered in home, center (office), daycare, preschool, or camp settings as indicated by assessment and treatment goals.Comprehensive ABA intensity defined as 30-40 hours/week when indicated.

Services may be focused or comprehensive depending on targets and intensity required.

Outpatient/community-based continued stay criteria: 1) Demonstrated progress on documented treatment goals; 2) Ongoing need for services documented by data collection and treatment modifications by LABA/BCBA or licensed psychologist; 3) Treatment remains medically necessary based on symptom severity and response to therapy.Comprehensive programs commonly 30-40 hours/week up to 40 hours/week.

Documentation must include data supporting progress and rationale for continued intensity.

ABA-Specific Clinical Criteria

General ABA Coverage Criteria

ABA services covered when provided for ASD and/or Down Syndrome and when clinical direction and implementation are by qualified personnel.

Covered diagnoses: 1) Individual has a diagnosis of autism spectrum disorder and/or Down Syndrome.

Policy explicitly adds Down Syndrome to medically necessary indications.

Qualified personnel: 1) Clinical direction provided by an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/BCBA; 2) Implementation by behavior technician, LABA/BCBA, or licensed psychologist as specified by service code.

LABA/BCBA or licensed psychologist must be on site when required by multi-technician services or per code definitions.

Service delivery and documentation: 1) Services administered face-to-face as specified by assessment or treatment code; 2) Individualized treatment protocols with data collection and documentation of progress; 3) Programs include training/guidance for families and generalization protocols.

Treatment Modalities

ABA (assessment, direct treatment, group, clinician-directed, caregiver guidance)

Included modalities: Behavior identification assessments (97151, 97152), multi-technician assessment/treatment (0362T, 0373T), adaptive behavior treatment by protocol (97153/97154), adaptive behavior treatment with protocol modification/clinician direction (97155), group adaptive behavior treatment with protocol modification (97158), and parent/caregiver guidance (97156/97157).

Each modality requires face-to-face delivery and appropriate provider qualifications as specified.

ABA — additional modality grouping

Additional modality grouping: 1) Multi-technician services apply when patient exhibits destructive behavior and require LABA/BCBA on site (0362T/0373T); 2) Group treatment (97158) addresses social skills and protocol modification in groups of 2–8 patients; 3) Clinician-directed services (97155) include observation and modification of technician-implemented protocols with recommended clinical direction ratio of 1–2 hours per 10 direct hours.97158 typical: 2 hours/week; 97155 typical ratio: 1–2 clinical hours per 10 direct hours.

Visit Limits and Intensity

inv-46: Comprehensive ABA treatment (individual and group face-to-face services inclusive) — visit limit: up to 40

Weekly visit limitComprehensive ABA treatment (individual and group face-to-face services inclusive): up to 40 visits per week

ScopeIncludes services provided by behavior technicians and LABA/BCBA across individual and group formats

Clinical justificationLimit aligns with definition of comprehensive ABA intensity (30–40 hours/week) and policy statement on inclusivity of group/individual services

inv-47: Comprehensive ABA direct individualized treatment hours — 30-40

Direct individualized treatment hours30–40 hours per week of direct individualized treatment for comprehensive ABA

Relation to visit limit

OpenPayer

Applied Behavior Analysis (ABA) services — coverage criteria

Coverage Criteria for ABA Services

Coding and Classification

Provider Actions, Authorization & Documentation

Background

Definitions and Service Descriptions

Level of Care Criteria

ABA-Specific Clinical Criteria

Treatment Modalities

Visit Limits and Intensity