Currentblue cross blue shield - michiganPolicy BH803ABASCC052024

Applied Behavior Analysis (ABA)

This policy describes medical necessity criteria, evaluation, treatment planning, provider qualifications, supervision, limitations/exclusions, and prior authorization requirements for Applied Behavior Analysis (ABA) services for autism spectrum disorder across member-specific plans and various state mandates. It is used to make coverage determinations and inform discharge planning for behavioral health benefit plans managed by The Health Plan/Blue Cross Blue Shield - Michigan.

Policy Summary

Payerblue cross blue shield - michigan

PolicyApplied Behavior Analysis (ABA)

Policy CodePolicy BH803ABASCC052024

Change TypeAnnual reviewInterim admission criteria update

Effective Date

Next Review DateDec 17, 2024

Key ActionObtain prior authorization and submit a documented comprehensive diagnostic evaluation demonstrating DSM-5-TR criteria plus treatment plan, baseline measures, caregiver training and supervision details.

SourceLink

POLICY UPDATE CHANGES

05/21/2024 Annual Review: Updates to align with CASP, 2024 guidelines and BACB Ethics Code for Behavior Analysts.

09/17/2024 Interim Review: Updates to admission criteria.

1Policy scope: ASD treatment coverage with state-specific variations

5+Major assessment tools listed

3Provider types specified (BCBA, BCaBA/RBT, licensed clinicians)

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Utilization attention threshold

2Typical treatment plan reviews per year

Coverage Summary

This Supplemental Clinical Criteria policy (Policy Number BH803ABASCC052024, status CURRENT) defines medical necessity criteria and prior authorization requirements for Applied Behavior Analysis (ABA) services for individuals with autism spectrum disorder (ASD). It is intended for use by behavioral health benefit plans managed by The Health Plan to standardize coverage determinations and support evidence-based care. ABA is covered with criteria when the policy's diagnostic, assessment, treatment planning, provider qualification, supervision, measurement, documentation, and coordination requirements are met. Prior authorization is required unless superseded by contract or applicable state mandate.

High-level thresholds and review cadence

Supervision percentageMinimum 5% of direct hours

Supervision general standardUp to 2 hours supervision per 10 hours of direct treatment (general standard)

Caregiver involvementCaregivers must be involved at minimum weekly; ideally at least 2 hours/month

Utilization Attention ThresholdPrior authorization period utilization below 80% requires attention; CASP: utilization below 80% over a 2-week period requires attention

last_review2024-05-21

next_review2024-12-17

Initial Coverage Criteria

Applied Behavior Analysis (ABA) is covered for the treatment of autism spectrum disorder in individuals when the following conditions are met:

ALL of the following

Prior authorization is required for ABA (unless otherwise required by contract/mandate)
Diagnosis: ASD or other applicable diagnosis by state mandate must be validated by a documented comprehensive diagnostic evaluation completed by a licensed physician, psychologist, or other licensed clinician qualified to diagnose Autism by state licensure demonstrating presence of DSM-5-TR criteria
See Diagnostic Evaluation section for required elements
Team composition: ensure age-appropriate disciplines represented on core team: Medical (family practice, pediatrician, developmental pediatrician, internal medicine physician, neurologist), Behavioral (psychiatrist, psychologist, neurologist), Speech and language therapist
Diagnosis tools

Diagnostic Evaluation (detailed criteria)

The ASD diagnosis must be validated by comprehensive assessment demonstrating DSM-5-TR diagnostic criteria and related evaluation elements:

Diagnostic Evaluation (top-level)

Core DSM-5-TR criteria: Persistent deficits in social communication and social interaction across multiple contexts; restricted, repetitive patterns of behavior, interests, or activities (at least two examples); symptoms present in early developmental period; symptoms cause clinically significant impairment; disturbances not better explained by intellectual disability
Assessment elements: Assessment may include screening instruments and psychiatric assessment instruments (examples: ABC, CARS, CHAT/M-CHAT, CSBS-DP-IT-Checklist, ASQ, AQ, CAST, ADI, ADOS, DISCO); observations; caregiver interviews; record review; cognitive/adaptive testing; sensory/hearing/vision assessments; genetic testing when appropriate; communication assessments when appropriate

Limitations and Exclusions

Limitations/Exclusions

ABA is not covered when any of the following apply:

Not meeting criteria: Programs or interventions that do not meet all of the above criteria
Not supervised: Programs not delivered by or under the supervision of an ABA-trained professional
Non-ASD targets: Programs that target mental disorders other than ASD as defined in DSM-5-TR (unless otherwise mandated by state)
IDEA services: Services otherwise covered under IDEA (eg, 1:1 aid in school during classroom instruction or treatment delivered simultaneously during classroom instruction) are not covered under ABA authorization

Elements of ABA Intervention (General Medical Necessity Considerations)

Covered when ALL of the following intervention elements are present:

Elements of ABA Intervention

Mitigate core features: Intervention mitigates the core features of ASD
Target specific deficits: Targets specific deficits related to social imitation, attending and social referencing, observational learning, play skills, social relationships, and reducing challenging behaviors
Measurable goals: Specific behaviors to be taught tie to objective and quantifiable treatment goals with baseline data, measurable progress, and projected timeframes

Treatment Intensity and Modality Considerations

Decision logic for intensity, modality and setting with ONE-of branch for Focused vs Comprehensive ABA:

Treatment Intensity and Modality

Intensity appropriateness: ABA is an intensive treatment; less intensive services may be appropriate if individual needs are lower (eg, individual or family therapy, speech therapy, occupational therapy)
ONE of
- Focused ABA: intended to reduce dangerous or maladaptive behavior and strengthen more appropriate functional behavior
- Comprehensive ABA: typically for earlier development, focuses on most areas of functioning to improve multiple skills

Parent / Caregiver Involvement and Training

Parent/Caregiver Involvement and Training

Requirements and expectations for parent/caregiver involvement and training:

Parent/Caregiver Involvement

Required training: Parent/caregiver training must be systematic, individualized curriculum on ABA fundamentals aiming for skill development so caregivers can implement strategies across settings
Prohibition parent as RBT: Caregivers should not act as RBTs/technicians; parent presence during technician-delivered sessions does not substitute for structured training
Documentation of attendance: Documentation must include description of interventions, goals, percentage of planned sessions attended, and plan for transitioning interventions to caregivers

Coordination of Care

Documentation expectations for coordination with other providers:

Content of documentation: Documentation should include types of therapy provided, number of therapies per week, behaviors/deficits targeted, progress related to services, measurable criteria for completing treatment, total days/week and hours/day of direct services, dates of service requested, licensure/credentials of providers, and evidence that parents/caregivers have been trained and consulted
Include IEPs, Early Intervention Plan or special education progress notes when applicable

Continued Treatment (Prior Authorization / Continued Medical Necessity Review)

Continued treatment is supported when ALL of the following are documented for prior authorization/continued review:

Continued Treatment

Updated plans: Updated treatment plan and progress reports submitted at each medical necessity review
Expectation of improvement: Reasonable expectation that behavior and skill deficits will continue to improve to a clinically meaningful and standardized extent with generalization and maintenance outside treatment environment
No worsening: Therapy is not making symptoms persistently worse and protocol modification has been ineffective at improving progress

Documentation Required (per member record)

ABA providers must maintain a separate member record containing ALL of the following required documentation:

Documentation Required

Comprehensive assessment establishing autism diagnosis or other appropriate diagnosis
Demographics/history: Demographics, complete developmental history and educational assessment
Functional behavioral assessment including assessment of targeted risk behaviors
Treatment history: Behavioral/medical treatment history: known conditions, dates and providers of previous treatment, current treating clinicians, current interventions and responses

Discharge Criteria

Discharge when ANY of the following documented and individualized reasons apply:

Goals met: Individual demonstrates improvement from baseline in targeted deficits and goals are achieved or maximum benefit reached
Plateau: Progress has reached a plateau or incremental progress is minimal despite treatment changes (including no progress on standardized adaptive measures)
No benefit: Individual is no longer benefiting as shown by lack of substantive progress across successive authorization periods in communication skills, social skills, or behavior challenges
Worsening:

Provider Actions and Billing Rules

Prior Authorization

Prior authorization required

Prior authorization is required for ABA services unless otherwise specified by contract or applicable state mandate.

Prior Authorization

Submit updated treatment plan and progress reports for continued authorization

At each medical necessity review submit an updated treatment plan and progress reports demonstrating movement from baseline using standardized assessments and the same modes of measurement used at baseline. Include rates/percentages of mastered programs and targets, change scores for outcome measures, updated standardized adaptive measures, evidence of caregiver progress in implementation, and transition planning for stepping down intensity as appropriate.

Updated treatment plan showing movement from baseline
Progress reports with mastery rates, change scores, and standardized measures
Evidence of caregiver training and implementation progress
Transition planning and step-down strategies

Coding

ICD-10 diagnoses referenced for ASDICD-10

F84.0-F84.9

Autism spectrum disorder diagnoses (range referenced in NJ Medicaid section)

Reference Diagnosis CodesICD-10

F84.0

Autistic Disorder

Background, Evidence, and Definitions

Background: The Supplemental Clinical Criteria provide objective, evidence-based behavioral health standards to guide coverage determinations and support recovery for behavioral health plans managed by The Health Plan. Applied Behavior Analysis (ABA) is described as an evidence-based, validated treatment for ASD, recognized by professional authorities and supported by extensive literature; the Supplemental Clinical Criteria summarize and operationalize these standards (including alignment updates to CASP 2024 and the BACB Ethics Code).

Source	Summary
CASP statement
ABA is a well-developed scientific discipline and the leading evidence-based, validated treatment for ASD per Council of Autism Service Providers (CASP, 2024).
CASP 2024 alignment
Policy updated to align with The Council of Autism Service Providers (2024) practice guidelines; annual review notes alignment with CASP (2024) and BACB Ethics Code.
Research on intensity
Cited research indicates limited evidence that higher hours necessarily yield better outcomes and no clear predictive relationship between number of treatment hours and positive outcomes.

Term	Definition
ABA
Applied Behavior Analysis: analysis, design, implementation, and evaluation of environmental modifications to produce meaningful changes in human behavior; evidence-based treatment for ASD.
BCBA
Board-Certified Behavior Analyst (Master's or Doctoral level credentialed provider).
BCaBA
Board-Certified Assistant Behavior Analyst (works under direct supervision of BCBA).
RBT
Registered Behavior Technician; paraprofessional technician role requiring supervision by BCBA.
Focused ABA
Intervention intended to reduce dangerous or maladaptive behavior and strengthen more appropriate functional behavior.
Comprehensive ABA
Services that focus on most areas of functioning, commonly for early development, intended to improve multiple skills.

Revision History

05/21/2024annual_review

Annual Review: Policy content updated to align with The Council of Autism Service Providers (CASP) 2024 practice guidelines and the Behavior Analyst Certification Board (BACB) 2024 Ethics Code for Behavior Analysts; reflected in Summary of Changes (Annual Review 05/21/2024).

09/17/2024interim_reviewLatest

Interim Review: Admission/diagnostic criteria updated — Summary of Changes notes an interim review on 09/17/2024 with updates to admission criteria.

Policy Summary

Payerblue cross blue shield - michigan

PolicyApplied Behavior Analysis (ABA)

Policy CodePolicy BH803ABASCC052024

Change TypeAnnual reviewInterim admission criteria update

Effective Date

Next Review DateDec 17, 2024

SourceLink

On This Page

Tools list: Autism Behavior Checklist (ABC); Childhood Autism Rating Scale (CARS/CARS-2); Checklist for Autism in Toddlers (CHAT; M-CHAT); Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist (CSBS-DP-IT-Checklist); Autism Screening Questionnaire (ASQ); Autism Quotient (AQ); Childhood Autism Screening Test (CAST); Autism Diagnostic Interview-Revised (ADI); Autism Diagnostic Observation Schedule (ADOS/ADOS-2); Diagnostic Interview for Social and Communication Disorders (DISCO)

Assessment before treatment: standard functional assessment and/or functional behavioral assessment when maladaptive behaviors present; interviews with caregivers; direct observation data; attention to coexisting medical conditions; record review of history, response to prior interventions, current treatments, cultural/familial considerations, language, and prior assessments

Initial Treatment provider qualifications: credentialed provider with ABA expertise identified (BCBA Master's/Doctoral or licensed behavioral health clinician credentialed to provide ABA); BCaBA or non-licensed individual may provide services under direct supervision of BCBA/licensed clinician; technicians (eg, RBT) must be under applicable supervision; parent as RBT discouraged/ethically problematic

Measurement and monitoring: baseline measurement and ongoing measurement determine treatment intensity; at least one listed tool used at baseline and repeated at least twice annually (ATEC, VB-MAPP, ABLLS/ABLLS-R, AFLS, PEAK, SSIS, RBS-R, SRS, VABS, CFQL-2); treatment intensity justified by clinical need; caregivers required to complete training and be involved at minimum weekly, ideally at least 2 hours/month; supervision proportional to dosage with minimum 5% of direct hours supervised (general standard up to 2 hours per 10 hours direct)

Treatment planning: standardized functional assessment, baseline skills, norm-referenced instruments as appropriate, coordinated with other professionals, treatment goals are comprehensive and measurable, include caregiver training, reviewed/updated twice annually as appropriate

Treatment details: Treatment: focus on socially significant behaviors, targeted, data-driven, includes caregiver training and generalization; treatment plans outline frequency/intensity/duration, setting, instructional methods, hours requested, schedule, and clinical justification of hours; treatment goals prioritized to address safety threats or barriers to quality of life; include replacement behaviors and skill acquisition goals based on assessments

Caregiver training: Includes parent/caregiver training and acquisition of skills for behavior modification to promote management and generalization of skills within the home

Alignment with scope/intensity: Treatment aligned with breadth and depth of behaviors targeted for the individual (scope, intensity, staffing, duration)

Review frequency: Treatment plans reviewed/updated twice annually as appropriate per state mandate and/or clinical presentation

Plan specifics: Treatment plan indicates treatment setting, instructional methods, hours requested, schedule, and clinical justification of hours; descriptions of replacement behaviors and skill acquisition goals based on assessments

Group ABA may be used when appropriate; treatment plan must include measurable goals specific to the individual's needs

Staffing ratios: When significant challenging behaviors exist, higher staff-to-patient ratio and on-site supervision may be needed; supervision responsive to needs (general standard up to 2 hours supervision per 10 hours direct)

Research note: Research: lack of high-quality evidence that more hours always lead to improved outcomes; no clear predictive relationship between hours and outcomes

Support groups: Parent support groups are considered not medically necessary

Documentation metrics: Progress documented for each targeted symptom/behavior using same modes of measurement as baseline, including rates/percentages of mastered programs, rates of mastered targets, change scores for outcome measures, updated standardized adaptive measures

Parent progress: Parent/caregivers are involved and making progress in their implementation of interventions

Transition planning documented to step down intensity over time and coordinate with other supports (eg, 1:1 to group, comprehensive to focused, center to community-based)

Inadequate progress rule: If inadequate progress for a 6-month period or goals not achieved within estimated timeframes, assessment of reasons and treatment changes must be documented; utilization below 80% of prior authorization period hours requires attention; per CASP utilization below 80% over a 2-week period requires attention

Individualized plans: Individualized treatment plan and all revisions, including objective measurable goals, parent/caregiver training, barriers, response to interventions

Daily progress notes documenting place of service, start/stop time, who rendered service, specific service, who attended, interventions during session, licensure/credentials of those in session

Supervision documentation: All documentation related to coordination of care and supervision of behavior technicians (including certification and credentials of professionals providing and supervising ABA)

Documentation Required

Comprehensive record keeping

Maintain a separate, legible record for each individual that contains: comprehensive assessment establishing the autism diagnosis (or other state-appropriate diagnosis); demographics, complete developmental history and educational assessment; functional behavioral assessment including targeted risk behaviors; behavioral/medical treatment history (conditions, dates/providers, current clinicians, current interventions and responses); individualized treatment plan and all revisions with objective measurable goals, parent/caregiver training, barriers and response to interventions; daily progress notes documenting place of service, start/stop times, who rendered the service, specific service, who attended, interventions during the session, and licensure/credentials of those in session; documentation related to coordination of care and supervision of behavior technicians; and certification and credentials of professionals providing and supervising ABA therapy. All documentation must be legible.

Comprehensive assessment establishing diagnosis
Demographics and developmental/educational history
Functional behavioral assessment and risk assessment
Behavioral/medical treatment history with dates/providers
Individualized treatment plan and revisions with measurable goals
Daily progress notes with start/stop times, provider, service, attendees, interventions, credentials
Coordination of care and supervision documentation
Provider certification and credentials
All documentation must be legible

Treatment is making deficits or behaviors persistently worse and protocol modification did not improve outcomes

Unlikely benefit: Individual is unlikely to continue to benefit or maintain long-term gains from continued ABA therapy

Caregiver/provider issues: Caregivers and provider are unable to reconcile important treatment planning/delivery issues

Caregiver refusal: Caregivers refuse treatment recommendations or do not follow through to an extent that compromises effectiveness

Improved functioning: Individual's physical/psychological well-being, independence and relationships have improved to the extent possible

Documentation Required

Comprehensive diagnostic evaluation documentation

Submit a documented comprehensive diagnostic evaluation demonstrating DSM-5-TR criteria completed by a licensed clinician qualified to diagnose autism. The evaluation should include use of recommended screening/diagnostic tools (e.g., ADOS/ADOS-2, ADI, CARS, M-CHAT, ABC, DISCO), record review, interviews with caregivers, direct observation data, and evidence of multidisciplinary team composition as appropriate.

Documentation demonstrating DSM-5-TR diagnostic criteria
Use of at least one listed screening/diagnostic tool
Record review, caregiver interviews, and direct observation
Team composition and qualified licensed clinician signature

Documentation Required

Treatment plan and assessments

Provide a standardized functional assessment and baseline measurement, a treatment plan with objective, measurable goals and justification for requested service hours, documentation of caregiver training involvement, and a supervision plan. Measurement tools (e.g., ATEC, VB-MAPP, ABLLS, VABS) should be used at baseline and repeated at least twice annually to monitor progress.

Standardized functional assessment informing baseline skills
Treatment plan with measurable goals and hours justification
Use of validated measurement tools at baseline and twice yearly
Documentation of caregiver training involvement
Supervision plan tied to treatment dosage

Documentation Required

Supervision documentation

Document supervision activities and proportions: supervision is proportional to treatment dosage and separate from direct treatment hours. A minimum of 5% of direct hours should be supervised; the general standard may be up to 2 hours of supervision per 10 hours of direct treatment. For paraprofessionals, document BCBA face-to-face supervision ratios as required by applicable state mandates.

Supervision is separate from direct treatment hours
Minimum 5% of direct hours must be supervised
General standard: up to 2 hours supervision per 10 hours direct treatment
Document BCBA face-to-face supervision ratios per state requirements

Billing Rule

Coordinate with member-specific benefits and state mandates

Review the member-specific benefit plan and any federal or state mandates prior to authorization. Member-specific benefits and applicable mandates supersede this guideline when they conflict with it.

Denial Risk

Risk of discontinuation if inadequate progress

Continued ABA may not be supported if there is inadequate progress for a 6-month period or specific goals are not met within estimated timeframes, or if therapy is making symptoms persistently worse despite modifications. Documentation must include assessment of reasons, treatment changes, and attention to utilization (prior authorization period utilization below 80% requires attention; per CASP utilization below 80% over a 2-week period requires attention).

Document inadequate progress assessment and reasons
Document treatment modifications or changes attempted
Monitor utilization; <80% use of authorized hours requires attention
Evidence that barriers to services were addressed

Documentation Required

Coordination of care documentation

Document communication and coordination with schools, early intervention, day care, preschools, and allied health providers. Documentation should include types and number of therapies provided, behaviors/deficits targeted, progress related to services, measurable completion criteria, total days/week and hours/day of direct services (including parent/caregiver training), dates of service requested, licensure/credentials of providers, and evidence that parents/caregivers have been trained and consulted.

Types and frequency of therapies
Behaviors/deficits targeted and progress
Measurable criteria for completing treatment and transition plans
Total days/week and hours/day of direct services
Dates of service requested and provider credentials
Evidence of parent/caregiver training and consultation

Billing Rule

Accurate service reporting

Behavior analysts must accurately identify services and include required information on reports, bills, invoices, and reimbursement requests. Do not bill nonbehavioral activities (for example, naps, meals without active goals, extended recreational reinforcement) under behavioral service authorizations. Ensure billing and reports reflect actual behavioral interventions and required details.

Include required information on reports, bills, and reimbursement requests
Do not bill nonbehavioral activities (naps, meals without goals) under ABA
Ensure billing reflects actual behavioral interventions and documentation