Utilization Management Criteria for Applied Behavior Analysis Treatment of Autism Spectrum Disorder
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Utilization-management criteria for admission, continued authorization, and discharge planning for ABA treatment of ASD for eligible Blue Cross commercial, Medicare Plus Blue, Blue Care Network commercial, and BCN Advantage members, subject to benefit eligibility, medical necessity, applicable mandates, and plan-specific rules.
Policy Summary
PayerBlue Cross Complete of Michigan
PolicyUtilization Management Criteria for Applied Behavior Analysis Treatment of Autism Spectrum Disorder
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJanuary 1, 2027
Next Review DateN/A
Key ActionObtain Blue Cross Behavioral Health approval before ABA treatment begins.
No material clinical or coverage changes in this revision.
4Coverage products
RequiredPrior approval
3Evaluation disciplines
RequiredADOS
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≥20%Improvement threshold
6 monthsReview interval
Coverage Criteria
General coverage requirements
Covered when all applicable requirements are met:
General coverage requirements: Services are medically necessary, fall within the member's benefit certificate, and use the most efficient method and scope of treatment that adequately meets the member's clinical needs. Services are reviewed and authorized by Blue Cross Behavioral Health before delivery by a contracted practitioner or organizational provider.
Benefits and eligibility, and applicable state and federal mandates, must be confirmed before authorization.
Initial ABA authorization
Initial ABA authorization requires all applicable elements:
Initial authorization: The member has a comprehensive diagnostic evaluation from an Approved Autism Evaluation Center or independent evaluation team; the evaluation establishes ASD through adequately licensed clinicians; ABA is recommended as an outcome of the evaluation; and Blue Cross Behavioral Health approves ABA before treatment begins.
Out-of-state ABA authorization
Out-of-state ABA authorization requires all applicable elements:
Out-of-state authorization: A multidisciplinary autism evaluation has been completed; the evaluation documents comprehensive treatment recommendations including ABA; the parent or guardian provides the evaluation results to the selected ABA provider; the provider is a participating board-certified behavior analyst in the state where services will be provided; and Blue Cross Behavioral Health approves treatment before it begins.
The evaluation or treatment provider must participate with the applicable Blue Cross or BCN plan in the state where services are provided.
Comprehensive diagnostic evaluation
The comprehensive diagnostic evaluation must include all of the following:
Evaluation components: The evaluation adequately assesses behavior, communication, and social interaction and includes an Autism Diagnostic Observation Schedule (ADOS), in-depth medical history and physical examination, psychiatric evaluation, speech pathologist evaluation, developmental and behavioral observations, interviews, and standardized age-appropriate testing.ADOS required
Testing should generally assess cognitive, adaptive, and language skills, sensory sensitivities, and processing difficulties. Examples of standardized instruments include ADOS, ADI-R, CARS-2, SCQ, ASRS, SRS, and GARS.
Evaluation team qualifications
The multidisciplinary autism evaluation team must include all of the following:
Required evaluation team: A board-certified pediatrician, developmental pediatrician, or pediatric neurologist; a fully licensed pediatric neuropsychologist, board-certified child psychiatrist, or fully licensed child psychologist; a speech and language therapist; and a qualified or trained professional who can perform ADOS.
All providers must be state-licensed and qualified to diagnose ASD according to DSM-5-TR criteria.
Initial ABA treatment authorization
Initial ABA treatment authorization requires all applicable provider, assessment, treatment-plan, and evidence requirements:
Functional and baseline assessment: The provider completes a Standard Function Assessment or, when maladaptive behaviors are present, a Functional Behavioral Assessment; obtains caregiver interviews and direct-observation data; reviews medical conditions, history, prior interventions, current treatments, cultural and familial considerations, language, and prior assessments; and establishes baseline skills.
Norm-referenced and skills-based assessments are used as appropriate.
Evidence-based proposed treatment: The proposed treatment follows current National Standards Report and National Autism Center guidelines, or an intervention outside those guidelines is supported by at least level B evidence.At least level B evidence for interventions outside guidelines
The treatment package or strategy must be clearly identified at authorization and reassessed through completion or maximization of benefit, including a plateau or new baseline.
Measurable goals and coordination:
Continuation of ABA authorization
Continued ABA benefits require all applicable criteria below:
Ongoing eligibility and defined targets: The member continues to meet admission criteria for the ASD treatment protocol, and specific treatment domains, skill deficits, targeted interventions, and longitudinal measures are identified.
Domains may include pre-academic, safety, social, play or leisure, community integration, vocational, coping and tolerance, adaptive and self-help, language and communication, attending, and inappropriate behaviors.
Progress review and plan adjustment: Documentation from the prior six months summarizes progress across goals, treatment changes, barriers and plan adjustments, generalization outside formal settings, newly identified diagnoses or problem behaviors, completed and replacement goals, and progress toward discharge.Prior six months
Expected clinical benefit: There is a reasonable expectation that continued ABA will produce clinically significant improvement in the member's skill areas.
Inadequate progress and medical review
When expected progress is not demonstrated:
Inadequate-progress response: If there has been inadequate or no clinically significant progress during the prior six months, the provider evaluates why, modifies the plan of care to achieve clinically significant progress, and specifies the improvement expected during the next measurement interval.Measurement interval no more than six months
Additional authorization of up to six months may be given. If adequate progress remains absent at the end of that period, medical review is required to determine whether further authorization is warranted.
Continued ABA treatment
Continued authorization is supported when all of the following remain true:
Continued ABA treatment: The member has shown objective improvement through ABA; the plan of care specifies expected improvement for the next interval; support-system involvement is active and constructive; interventions are provided in a home, clinic/outpatient, or community setting unless another setting is clearly justified; and baseline diagnostic testing is repeated and reported at least yearly.At least 20% objective improvement within no more than six months; baseline testing at least annually
If baseline testing shows no change, repeat it in six months and reconsider whether the member is benefiting from this level of care.
Discharge from ABA treatment
Discharge from ABA treatment is appropriate when one or more of the following conditions is met:
Discharge conditions: The member no longer meets criteria for ASD as the primary diagnosis, unless another state-mandated ABA indication applies; treatment goals and objectives are complete; goals remain unmet despite plan-of-care revision and symptoms warrant another level of care, setting, or intervention; further clinically significant improvement is not expected; ABA worsens symptoms or behaviors; the support system has been trained to maintain social function without treatment; the member or support system requests discontinuation; or the member or family cannot agree with the provider on important treatment-planning or delivery issues.One or more conditions
Discharge planning begins at treatment initiation. Transition to a lower level of care or different modality should generalize progress to school, community, and family life. Lower-intensity treatment may remain medically necessary to maintain stability, prevent deterioration, or preserve functional gains.
Court-ordered treatment or treatment provided to prepare for a legal defense is not sufficient by itself to meet coverage criteria or support treatment authorization at any level of care.
ABA is not appropriate when it is directed at symptoms or behaviors related to a diagnosis other than autism spectrum disorder (ASD), except where state regulations determine otherwise.
ABA may not replace or duplicate services delivered during classroom instruction or services covered under the Individuals with Disabilities Education Act (IDEA).
Court-ordered treatment or treatment intended to prepare for a legal defense is not sufficient by itself to meet continuing authorization criteria.
Court-ordered treatment or treatment intended to prepare for a legal defense is not sufficient by itself to support treatment at discharge or any other level of care.
ABA treatment is no longer medically necessary at the current intensity when the member no longer requires that intensity and can be safely transitioned to a lower level of care. Lower-intensity services may remain appropriate to maintain stability, prevent relapse, or support functioning.
ABA treatment should be discontinued when it is no longer expected to produce additional clinically significant improvement in symptoms or functioning, or when treatment has worsened the member's symptoms or behaviors and is no longer appropriate.
Authorization and Documentation Requirements
Prior Authorization
Blue Cross Behavioral Health Authorization
Obtain review and approval from Blue Cross Behavioral Health before services begin. Confirm member eligibility, benefits, applicable state and federal mandates, and use a contracted practitioner or organizational provider.
Prior Authorization
Requirements for ABA Benefits
To obtain the Michigan-mandated ABA benefit, the member must have a multidisciplinary diagnosis of ASD, a treatment recommendation that includes ABA, and approval from Blue Cross Behavioral Health. The medical director may authorize treatment when the applicable ASD medical policy criteria for medical necessity are met.
Documentation Required
In-State Authorization
For an in-state authorization, obtain a comprehensive diagnostic evaluation from an Approved Autism Evaluation Center or independent evaluation team. The evaluation must establish ASD through adequately licensed clinicians and recommend ABA treatment.
Policy Background
Autism spectrum disorder (ASD) involves persistent deficits in social communication and interaction, including social-emotional reciprocity, nonverbal communication, and developing or maintaining relationships, together with restricted or repetitive patterns of behavior. These patterns may include stereotyped movements or speech, insistence on sameness, highly restricted or fixated interests, and sensory reactivity, and may cause significant impairment in social, occupational, educational, or other functioning.
Definitions
DSM
DefinitionThe most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
Current edition referencedDSM-5-TR (5th edition).
Publication referenceAmerican Psychiatric Association, March 2022.
Autism spectrum disorder
DefinitionA condition characterized by significant impairment associated with persistent deficits in social communication and interaction and restricted, repetitive patterns of behavior.
Social-communication impairmentsPersistent challenges with social and emotional reciprocity, nonverbal communication, and developing or maintaining relationships.
Level of Care Criteria
Outpatient ABA
For outpatient ABA, continued stay and discharge determinations must reflect medical necessity and functional needs:
Continued-stay criteria: The member continues to demonstrate measurable benefit from ABA, with objective improvement, an active support system, a documented plan for expected improvement, appropriate treatment setting, and ongoing reassessment.At least 20% objective improvement within no more than six months
Preferred settings are home, clinic/outpatient, and community. Additional authorization may be up to six months; further authorization requires medical review if adequate progress remains absent.
Discharge or transition: The member no longer requires the current intensity and can safely transition to a lower level of care; treatment goals are complete; treatment is no longer expected to provide clinically significant improvement; ABA worsens symptoms or behaviors; the support system can maintain social function; or the member or support system requests discontinuation or cannot agree with the provider on treatment delivery.One or more conditions
Transition planning begins at treatment initiation and should generalize progress to natural environments.
Applied Behavior Analysis Criteria
ABA authorization criteria
ABA benefits require all applicable elements:
ABA authorization: The member has a qualifying comprehensive multidisciplinary autism evaluation; the evaluation establishes ASD through adequately licensed clinicians; ABA is recommended; and Blue Cross Behavioral Health approves treatment before services begin.
For out-of-state services, the evaluation must include comprehensive treatment recommendations with ABA, and the treatment provider must be a participating board-certified behavior analyst in the service state.
Applied Behavior Analysis
ABA treatment is authorized initially and continued only when all applicable criteria are satisfied:
Provider and supervision: A credentialed BCBA or licensed and credentialed behavioral health clinician provides or directs treatment, with BCaBAs and technicians working under applicable direct supervision.
Related Treatment Modalities
Related autism and behavioral health services
Related services may be recommended when clinically appropriate and coordinated across settings:
Related evidence-based services: Recommendations may include speech therapy, occupational therapy, physical therapy, nutritional counseling, social-skills training, parent education or support, psychotherapy, psychiatry, medication management, and other evidence-based interventions that improve symptoms, behavior, functioning, and integration across school, community, and home settings.
Coordinate care with school personnel, medical providers, and the primary care physician as applicable.
Measurement and Authorization Intervals
ABA treatment
Progress review intervalMeasurement and progress review must occur at least every six months; the applicable measurement interval may be no more than six months.
Objective improvement thresholdContinued ABA authorization requires at least 20% improvement based on objective measurements, including therapy data and an assessment scale.
Additional authorizationAdditional authorization of up to six months may be given when adequate progress has not yet been achieved but the plan of care specifies expected improvement.
Medical reviewIf adequate progress remains absent at the end of the additional period, medical review is required to determine whether further authorization is warranted.
Policy Summary
PayerBlue Cross Complete of Michigan
PolicyUtilization Management Criteria for Applied Behavior Analysis Treatment of Autism Spectrum Disorder
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJanuary 1, 2027
Next Review DateN/A
Key ActionObtain Blue Cross Behavioral Health approval before ABA treatment begins.
The plan addresses measurable symptoms, behaviors, skills, and functioning and coordinates care with relevant providers and settings. Related services may include speech, occupational or physical therapy, nutritional counseling, social-skills training, parent education or support, behavioral health services, and other evidence-based interventions.
Individualized service intensity: The requested amount and scope reflect current symptoms, behaviors, and progress or lack of progress, with intensity, duration, and frequency adjusted as the member changes.
Outcome measurement: An Autism Social Skills Profile, Social Skills Rating System, Social Skills Checklist, or comparable validated instrument established at baseline is updated at least every six months and shows expected progress or prompts an appropriate plan modification.At least every six months
Objective improvement: The member demonstrates improvement through ABA during a measurement interval based on objective measurements, including therapy data and an assessment scale.At least 20% improvement; interval no more than six months
Preferred scale: VBMAPP. Other listed scales include the Vineland Adaptive Behavior Scale, ADOS, ASSP, or a similar instrument.
Support-system involvement: The support system is actively and constructively involved in therapy to facilitate improvement in social interaction.
Examples include primary care visits, psychiatric recommendations, medication adherence, family counseling, and individual counseling.
Prior Authorization
Out-of-State Authorization
For an out-of-state member, obtain a multidisciplinary autism evaluation. The parent or guardian must ensure comprehensive treatment recommendations include ABA, provide the evaluation to the selected ABA provider, and obtain Blue Cross Behavioral Health approval before treatment begins.
Documentation Required
Identify the Proposed Treatment
Identify the proposed treatment package or strategy when requesting authorization. The treatment should follow current National Standards Report and National Autism Center guidelines; an intervention outside those guidelines requires at least level B evidence.
Prior Authorization
Continued ABA Authorization
For continued ABA authorization, show ongoing admission eligibility, specific treatment domains, measurable skill deficits and targets, and progress or lack of progress during the prior six months. Requested intensity, duration, and frequency must reflect the member’s clinical response and changing needs.
Prior Authorization
Progress-Based Authorization
Specify the improvement expected within a measurement interval of no more than six months and document at least 20 percent improvement based on objective measurements. If adequate progress is not achieved, explain why and revise the plan of care.
Prior Authorization
Alternate Treatment Setting
Use home, clinic or outpatient, and community settings unless the request includes clear and convincing reasons for a different setting. Identify why the alternate setting is clinically appropriate.
Prior Authorization
Additional Authorization and Medical Review
When adequate progress has not been made, up to six additional months may be authorized. If progress remains inadequate at the end of that period, medical review is required to determine whether further authorization is warranted.
Documentation Required
ASD Treatment Medical-Record Documentation
Follow Blue Cross and BCN requirements for adequate medical-record documentation for ASD treatment. Use the applicable Behavioral Health medical record documentation requirements for autism treatment services.
Documentation Required
Comprehensive Diagnostic Evaluation Records
Document the comprehensive diagnostic evaluation, including assessment of behavior, communication, and social interaction; ADOS; medical history and physical examination; psychiatric and speech-language evaluations; observations; interviews; and standardized testing.
Include cognitive, adaptive, language, sensory, and processing assessments when applicable.
Document testing such as ADOS, ADI-R, CARS-2, SCQ, ASRS, SRS, or GARS when used.
Documentation Required
Evaluator Qualifications
Identify the multidisciplinary evaluators and document that each is state-licensed and qualified under DSM-5-TR diagnostic criteria. The team includes appropriate medical, behavioral, speech-language, and ADOS-qualified professionals.
Medical: board-certified pediatrician, developmental pediatrician, or pediatric neurologist.
Include a speech and language therapist and a qualified professional who can perform ADOS.
Documentation Required
Out-of-State Treatment Recommendations
For out-of-state treatment, document comprehensive recommendations from the multidisciplinary evaluation, including ABA. Direct the evaluation results to a board-certified behavior analyst who participates with the applicable Blue Cross or BCN plan in the state where services will be provided.
Documentation Required
ABA Baseline and Functional Assessment
Complete a standard function assessment or, when maladaptive behaviors are present, a functional behavioral assessment. Include caregiver interviews, direct observation, baseline skills assessment, relevant history, prior intervention response, current treatment, cultural and familial considerations, language, and coexisting medical conditions.
Use norm-referenced and skills-based assessments to establish functioning, develop goals, and measure developmental gains.
Collaborate with qualified professionals when comorbid conditions increase risk of harm.
Documentation Required
Treatment Package and Reassessment
Clearly identify the treatment package or strategy at authorization and reassess it based on progress through completion or maximization of benefit, including a plateau or new baseline. Treatment outside recognized guidelines requires sufficient supporting evidence.
Documentation Required
Six-Month Continuation Review
For the six-month continuation review, identify treatment domains, deficits, targeted interventions, longitudinal measures, progress across goals, barriers, plan changes, generalization outside formal treatment, new diagnoses or behaviors, achieved and replacement goals, and progress toward discharge or less intensive care.
Potential domains include pre-academic, safety, social, play or leisure, community integration, vocational, coping and tolerance, adaptive and self-help, language and communication, attending, and inappropriate behaviors.
Document the rationale for requested intensity, duration, and frequency.
Documentation Required
Social-Skills Outcome Measurement
Update the Autism Social Skills Profile, Social Skills Rating System, Social Skills Checklist, or another validated instrument identified at baseline at least every six months. Report expected progress or explain how the plan of care was modified when expected progress was not demonstrated.
Documentation Required
Objective Outcome Documentation
Document the improvement expected during the next measurement interval, which may not exceed six months, and provide objective measurement data supporting the outcome.
Documentation Required
Support-System Involvement
Document active, engaged, and constructive support-system participation that facilitates improvement in the member’s social interaction and overall treatment response.
Examples include primary care visits, ABA therapy, psychiatric recommendations, medication adherence, family counseling, and individual counseling.
Documentation Required
Progress and Treatment Goals
State the expected improvement and define measurable treatment goals for the identified skill domains. Goals must support longitudinal measurement and guide intervention changes.
Documentation Required
Objective Assessment Data
Include therapy-session data and standardized assessment instruments in the progress record. Measures may include VBMAPP, Vineland Adaptive Behavior Scale, ADOS, Autism Social Skills Profile, or similar instruments.
Documentation Required
Support-System Involvement
Show that the support system participates in a manner that facilitates improvement in social interaction, including implementation and generalization of treatment strategies when appropriate.
Documentation Required
Baseline Testing
Repeat and report the diagnostic baseline testing at least annually. If there is no change, repeat it again in six months; continued lack of change may require adjustment or reconsideration of the current level of care.
Documentation Required
Plan-of-Care Revision and Transition
If goals are not achieved despite plan-of-care revisions, document the limited progress, the revisions attempted, and why another level of care, treatment setting, or intervention is warranted. Transition to lower-intensity care when appropriate.
Billing Rule
Benefit, Medical-Necessity, and Efficiency Requirements
Before authorization, verify member eligibility and benefit coverage, applicable state and federal mandates, medical necessity, and the most efficient method and scope of treatment that adequately meets clinical needs. Coordinate the appropriate level of care and transitions when benefits end.
Denial Risk
Insufficient Basis for Authorization
Court-ordered treatment or treatment intended to prepare for legal defense is not, by itself, sufficient clinical criteria for authorization.
Denial Risk
Missing Evaluation or Prior Approval
Authorization is at risk when the required evaluation, ASD diagnosis, ABA recommendation, or Blue Cross Behavioral Health approval is missing. Approval must be obtained before treatment begins.
Denial Risk
Out-of-State Network Requirements
For out-of-state services, the evaluation facility must participate with Blue Cross or BCN in the state where services will be provided. The treatment provider must also participate with the applicable Blue Cross or BCN plan in that state; verify network status before scheduling the evaluation.
Denial Risk
Non-ASD or Duplicative Services
ABA is not appropriate for symptoms or behaviors attributable to diagnoses other than ASD, except as permitted by state regulation. Do not use ABA to replace or duplicate classroom instruction or services covered under IDEA.
Denial Risk
Provider Credentialing Deficiencies
Treatment must be delivered by a credentialed ABA provider meeting applicable qualifications, such as an in-network BCBA or a licensed and credentialed behavioral health clinician. Assistants and technicians must work under required supervision, and telehealth clinicians must meet licensure and credentialing requirements at their location.
A BCaBA or appropriately certified technician may assist under direct supervision.
Parents are generally not recommended to serve as their own child’s BT or RBT because of ethical and conflicting-relationship concerns.
Denial Risk
Unsupported or Undefined Intervention
An intervention outside current National Standards Report or National Autism Center guidelines requires at least level B evidence supporting authorization. Undefined or unsupported interventions may not be authorized.
Denial Risk
Insufficient Legal-Purpose Rationale
A court order or legal-defense purpose alone does not establish medical necessity or support authorization. The request must satisfy the clinical and benefit criteria.
Denial Risk
Failure to Meet Continuation Criteria
Continuation requires ongoing admission eligibility, clearly identified treatment domains, measurable deficits and targets, longitudinal measurement, and documentation of progress or lack of progress during the prior six months.
Denial Risk
Insufficient Objective Progress
Less than 20 percent objective improvement during the measurement interval requires an evaluation of the reasons for inadequate progress and a documented plan-of-care modification. Additional authorization is limited and may require medical review.
Denial Risk
Unjustified Treatment Setting
An alternate treatment setting requires clear and convincing clinical justification. Requests outside home, clinic or outpatient, and community settings may be denied without that rationale.
Denial Risk
Inadequate Clinical Progress
Authorization is at risk when clinically significant progress is inadequate or absent. Explain barriers, modify the plan of care, and demonstrate a reasonable expectation of clinically significant improvement with continued treatment.
Denial Risk
Failure After Additional Authorization
After an additional authorization period of up to six months, further authorization requires medical review if adequate progress remains absent.
Denial Risk
Nonstandard Treatment Setting
Settings other than home, clinic or outpatient, and community require clear and convincing justification in the authorization request. Specify why the nonstandard setting is necessary.
Denial Risk
Insufficient Legal Basis
Court-ordered treatment or treatment requested solely for legal defense does not, by itself, support treatment authorization.
Denial Risk
Treatment No Longer Appropriate
Discontinue or transition ABA when further clinically significant improvement is not expected, symptoms or behaviors worsen, treatment goals remain unmet despite plan revisions and another level of care is needed, or the member or support system requests discontinuation. Document transition planning and any lower-level services needed to maintain stability.
Discharge may also occur when the support system has been trained to maintain social functioning without treatment or when agreement on important treatment-planning issues cannot be reached.
Restricted or repetitive behaviorAt least two patterns such as stereotyped or repetitive movements or speech, insistence on sameness, highly restricted or fixated interests, or unusual sensory reactivity.
Functional impactImpairment may affect social, occupational, educational, or other areas of functioning.
ADOS
Full nameAutism Diagnostic Observation Schedule.
PurposeA standardized component of the comprehensive multidisciplinary autism evaluation.
Evaluation roleADOS is required and supports assessment of behavior, communication, and social interaction.
ADOS-qualified professional
DefinitionA qualified or trained professional who can perform an Autism Diagnostic Observation Schedule assessment.
Qualification requirementThe professional must be state-licensed and qualified to make an ASD diagnosis according to DSM-5-TR diagnostic criteria when performing the applicable diagnostic role.
Evaluation roleThe professional is a required member of the multidisciplinary autism evaluation team.
Autism Spectrum Disorder diagnosis
Qualified providerThe diagnosis must be made by a state-licensed and qualified provider.
Diagnostic standardThe provider must use diagnostic criteria based on the DSM-5-TR.
Required evaluation basisDiagnosis follows a multidisciplinary evaluation that assesses behavior, communication, and social interaction and includes ADOS, medical and psychiatric evaluation, speech-pathology evaluation, developmental and behavioral observations, interviews, and standardized age-appropriate testing.
Credentialed ABA provider
BCBA optionA master- or doctoral-level Board-Certified Behavior Analyst who is in-network with Blue Cross or BCN.
Licensed clinician optionA behavioral health clinician who is licensed and credentialed to provide ABA services in the state where treatment is provided.
Supervised personnelA BCaBA or non-licensed individual may assist with assessment or implement a plan of care under the direct supervision and responsibility of a BCBA or licensed behavioral health clinician.
Telehealth requirementFor telehealth services, the clinician must also be licensed and credentialed in the state where the clinician is located.
Standard Function Assessment or Functional Behavioral Assessment
Standard Function AssessmentAn assessment of behavior and function used to develop treatment goals.
Functional Behavioral AssessmentUsed when maladaptive behaviors are present.
Related assessment informationAssessment is informed by caregiver interviews, direct observation data, coexisting medical conditions, treatment history, prior interventions, current treatments, and baseline skills.
Assessment-driven treatment: Treatment is informed by functional or standard assessment, caregiver interview, direct observation, relevant medical and treatment history, baseline skills, and norm-referenced or skills-based measures as appropriate.
Evidence-based treatment plan: The proposed treatment package or strategy is clearly identified, follows current National Standards Report or National Autism Center guidelines, or has at least level B evidence when outside those guidelines.At least level B evidence for interventions outside guidelines
Measurable goals and continuation: Treatment targets defined deficits with longitudinal measures and requires documented progress or a clinically justified modified plan, a reasonable expectation of clinically significant improvement, and objective improvement during a measurement interval of no more than six months.At least 20% objective improvement; interval no more than six months
ABA continued-stay criteria
ABA continued-stay treatment requires all of the following:
Continued-stay requirements: The member demonstrates at least 20 percent objective improvement within a measurement interval of no more than six months; therapy-session data and standardized assessment scales are used; the support system is active and constructive; treatment occurs in a home, clinic/outpatient, or community setting unless another setting is clearly justified; and baseline diagnostic testing is repeated and reported at least annually.≥20% improvement; interval ≤6 months; baseline testing at least yearly
If baseline testing is unchanged, repeat it in six months and reconsider the treatment level. Measures may include VBMAPP, Vineland Adaptive Behavior Scale, ADOS, ASSP, or a similar instrument.
ABA discharge criteria
Discharge must be considered from treatment initiation and should include transition and generalization planning:
Discharge criteria: Discharge when the member no longer requires the current intensity and can safely transition to a lower level of care; treatment goals are complete; goals remain unmet despite plan revision and another level or type of intervention is warranted; further clinically significant improvement is not expected; ABA worsens symptoms or behaviors; the support system is trained to maintain social function; the member or support system requests discontinuation; or the member or family cannot agree with the provider on important treatment issues.One or more conditions
Progress should generalize to school, community, and family life. Less intensive treatment may remain medically necessary to maintain stability, prevent deterioration, or preserve functional gains.