CurrentBlue Cross Complete of MichiganPolicy BH803ABASCC042023

Applied Behavior Analysis (ABA) Supplemental Clinical Criteria

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Guides coverage determinations, evidence-based treatment discussions, and discharge planning for ABA services under behavioral health benefit plans, subject to member-specific benefits, applicable mandates, and regulatory requirements.

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyApplied Behavior Analysis (ABA) Supplemental Clinical Criteria

Policy CodePolicy BH803ABASCC042023

Change TypeAnnual reviewno material change

Effective DateN/A

Last ReviewApr 18, 2023

Next Review DateApril 18, 2023

Key ActionObtain prior authorization before providing applied behavior analysis services.

SourceLink

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CurrentBlue Cross Complete of MichiganPolicy BH803ABASCC042023

Applied Behavior Analysis (ABA) Supplemental Clinical Criteria

Customize your policy alerts

Sign up for blue_cross_complete_of_michigan Policy BH803ABASCC042023 alerts

Get alerted when Policy BH803ABASCC042023 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Complete of Michigan

PolicyApplied Behavior Analysis (ABA) Supplemental Clinical Criteria

Policy CodePolicy BH803ABASCC042023

Change TypeAnnual reviewno material change

Effective DateN/A

Last ReviewApr 18, 2023

Next Review DateApril 18, 2023

Key ActionObtain prior authorization before providing applied behavior analysis services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior authorization for ABA

Up to age 21Supported age range

30 hours/weekMassachusetts Early Intervention ABA limit

2:10General supervision standard

6 monthsContinued-treatment progress review

Coverage Criteria

General ABA coverage criteria

ABA is covered when all of the following conditions are met.

General ABA coverage conditions

Treatment approach: The intervention is a systematic approach based on the principles of comprehensive applied behavior analysis.
Treatment target: The intervention targets the core deficits of autism spectrum disorder as outlined by DSM-5-TR.
Treatment setting: The intervention is delivered in a home, center or office, or community setting as clinically indicated.
Qualified personnel: The intervention is rendered directly by a BCBA, a licensed mental health clinician with additional documented ABA training, or a paraprofessional under the direct supervision of such professionals.
Intensity and measurement: The intervention is delivered with an appropriate level of intensity and includes ongoing measurement of efficacy, continuous use of measurement tools and progress analysis, and treatment decisions based on objective assessment results.
Least restrictive care: ABA is provided at the least restrictive and most clinically appropriate level to safely, effectively, and efficiently meet the individual's needs.
Therapeutic purpose: ABA is needed for reasons other than the convenience of the individual, family, physician, or others and is expected to produce therapeutic results for the individual.

Age and evidence considerations

Treatment requests for adults are clinically reviewed under these evidence considerations.

Population and evidence considerations: ABA treatment is well supported for children and adolescents up to age 21 with autism spectrum disorder; evidence for young adult populations and diagnoses other than autism spectrum disorder is limited.

Adult requests require clinical review.

Indiana service intensity

For Indiana members, service intensity is individualized.

Indiana individualized intensity

Services may be intensive and provided daily.
Determinations are based on the individualized objectives of the treatment plan and the member's unique needs.
Intensity considers the member's ability to participate in, benefit from, and tolerate the full spectrum of services.

New Jersey Medicaid ABA criteria

For New Jersey Medicaid members, ABA is available based on medical necessity when all of the following apply.

New Jersey Medicaid eligibility and planning

The child is diagnosed with autism spectrum disorder under ICD-10 diagnoses F84.0 through F84.9.
The child is 18 months to 21 years of age.18 months to 21 years
A qualified healthcare professional capable of diagnosing autism, such as a physician or psychologist, determines the diagnosis.
A qualified healthcare professional, such as a BCBA, assesses the child for ABA need and develops the treatment plan.

New York Medicaid ABA criteria

For New York Medicaid members, eligibility requires all of the following.

New York Medicaid eligibility

The enrollee is under age 21.Under age 21
The enrollee has autism spectrum disorder and/or Rett Syndrome as defined by DSM-5.
The enrollee is referred for ABA by a New York-licensed and New York Medicaid-enrolled physician.
Services are provided by a Licensed Behavior Analyst, a Certified Behavior Analyst Assistant under Licensed Behavior Analyst supervision, or another individual permitted under Article 167 of New York education law.

Washington Medicaid inpatient criteria

For Washington Medicaid inpatient ABA, all additional inpatient criteria must be met.

Washington inpatient ABA

Services are ordered by an ABA Center of Excellence provider.
Less costly and less intrusive interventions have failed, or no equally effective and substantially less costly alternative treatment is available.
The evaluating and prescribing provider reasonably expects the requested ABA services to result in measurable improvement in the client's behavior or skills.
Severe harmful behavior is preventing discharge to a less restrictive setting.
Treatment is short-term and focused to stabilize harmful behavior to a level or intensity that promotes discharge to a less restrictive setting.

Covered ABA services

ABA is covered when all of the following conditions are met.

Covered ABA conditions

The intervention is systematic and based on comprehensive applied behavior analysis principles.
The intervention targets the core deficits of autism spectrum disorder as outlined in DSM-5-TR.
The intervention is delivered in a home, center or office, or community setting as clinically indicated.
The intervention is rendered directly by a BCBA or qualified licensed mental health clinician with documented ABA training, or by a paraprofessional under direct supervision.
The intervention is delivered at an appropriate intensity with continuous measurement and objective analysis of efficacy.

Diagnostic evaluation

The ASD diagnosis must be validated by a comprehensive assessment demonstrating the applicable DSM-5-TR criteria.

Autism spectrum disorder diagnostic criteria

Persistent deficits in social communication and social interaction occur across multiple contexts.
At least two restricted, repetitive patterns of behavior, interests, or activities are present.At least 2
Symptoms are present in the early developmental period.
Symptoms cause clinically significant functional impairment.
The disturbances are not better explained by intellectual disability or global developmental delay.

Assessment components

The comprehensive evaluation should include clinically appropriate components.

Comprehensive ASD assessment components

Standardized screening or rating instruments are used as appropriate.
Psychiatric assessment and observation tools are used as appropriate.
Interviews with the individual and family are completed.
Records and developmental, family, psychosocial, and functional history are reviewed.
Cognitive, adaptive, sensory, language, and communication abilities are assessed.

Treatment planning and implementation

The ABA treatment plan must be individualized, outcome-oriented, coordinated, and continuously updated.

Treatment planning and delivery requirements

Assessment and functional behavior information are used to develop the treatment plan.
Specific deficits, maladaptive behaviors, replacement behaviors, and skill-acquisition goals are identified.
Objective baseline data, measurable goals, projected completion timeframes, treatment setting, methods, intensity, duration, and requested hours are established.
Caregiver training and strategies for generalization and maintenance are included.
Care is coordinated with schools and other providers.

Intensity and duration

Treatment intensity and duration must be clinically justified and responsive to the member's needs.

Intensity and duration justification

Requested intensity and duration are supported by changes in targeted behaviors and response to treatment.
Caregiver management skills are considered.
The suitability of group formats for particular issues is considered.
Participation in school or other settings is considered.
Co-occurring behavioral or medical conditions are considered.

Continued ABA treatment

Continued ABA treatment requires all of the following to support ongoing medical necessity.

Continued-treatment criteria

The treating clinician reasonably expects clinically meaningful improvement in behavior and skill deficits in at least two settings, such as home, school, or community.At least 2 settings
Treatment is not persistently worsening symptoms or behaviors.
Progress is documented for each targeted symptom and behavior using baseline-consistent measures.
Parents or caregivers are involved and progressing in their own intervention skills.
The treatment plan includes a transition of service intensity over time.

Continued treatment

Continued ABA treatment is supported when all of the following are met.

The child's behavior and skill deficits are expected to continue improving to a clinically meaningful extent with ABA services in at least two settings.At least 2 settings
Therapy is not persistently worsening symptoms or behaviors.
Progress is assessed and documented for every targeted symptom and behavior using the same measurement methods as baseline.
Adaptive functioning is assessed with validated measures.
Parents or caregivers are involved and progressing in their own behavioral interventions.

Treatment modification and transition

When progress is inadequate or goals are achieved, the treatment plan must be revised as applicable.

Required response to inadequate progress or achieved goals

Inadequate or absent progress: When progress is inadequate or absent, document the reasons and modify treatment by increasing time or frequency, changing techniques, increasing caregiver training, identifying and resolving barriers, addressing a newly identified coexisting disorder, or reconsidering goals.No demonstrable progress within 6 months
Goals achieved: When goals are achieved, identify new goals addressing symptoms or behaviors that limit age-appropriate participation or create safety risks, or transition to less intensive interventions.

Discharge criteria

The child is considered discharged and further ABA services are not covered when any of the following applies.

Discharge

Treatment goals are achieved or maximum benefit has been reached.
There is no clinically significant progress or measurable improvement for at least three months in adaptive functioning, communication, language, or social skills.At least 3 months
Treatment persistently worsens deficits or behaviors.
The child is unlikely to continue benefiting from or maintaining long-term gains from ABA therapy.
Parents or caregivers refuse, cannot participate in, or fail to follow recommendations to an extent that compromises treatment effectiveness.

Services otherwise covered under the Individuals with Disabilities Education Act (IDEA) are not covered under this policy. This includes a one-to-one aid in the school setting; covered school-related ABA services may instead include coordination, teacher training, meetings with school personnel, and school observations.

Programs or interventions directed at mental disorders other than autism spectrum disorder, as defined by the DSM-5-TR, are considered unproven and are not covered under these ABA criteria.

ABA must be delivered directly by a Board-Certified Behavior Analyst (BCBA), a licensed mental health clinician with documented ABA training, or a paraprofessional working under the direct supervision of one of these qualified professionals. Programs that do not meet this supervision requirement are unproven.

A one-to-one school aid and other services otherwise covered under the Individuals with Disabilities Education Act (IDEA) are excluded from coverage under this policy. School-based ABA activities that coordinate services, train teachers, involve meetings with school personnel, or include school observations may be covered when otherwise medically necessary.

Parent support groups are not medically necessary under this policy. Parent and caregiver participation, individualized training, and follow-through with treatment recommendations remain expected components of an ABA program.

Further ABA services are not covered after the child meets discharge criteria, including achievement of treatment goals or maximum benefit, no clinically significant progress or measurable improvement for at least 3 months, persistent worsening, unlikely continued benefit, or caregiver participation problems that compromise treatment effectiveness.

ABA is not medically necessary when requested for the convenience of the individual, family, physician, or others, or when it is not reasonably expected to produce therapeutic results for the individual.

Programs or interventions are considered unproven when they fail to meet all applicable proven ABA conditions, are not delivered by or under the supervision of an ABA-trained professional, or target a mental disorder other than autism spectrum disorder as defined by the DSM-5-TR.

ABA services are not covered as duplicative treatment when they duplicate services provided to or available from other medical or behavioral health providers. Examples include individual, group, or family therapy, occupational therapy, and speech therapy; care should be coordinated to reduce unnecessary duplication.

Coding and Service Parameters

New Jersey Medicaid qualifying autism spectrum disorder diagnosesICD-10Covered

F84.0-F84.9

Autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9

CPT CodesCPT

97151	Behavior identification assessment by a physician or other qualified healthcare professional, including assessment administration, discussion of findings and recommendations, data analysis, scoring/interpreting, and report/treatment-plan preparation.
97157	Family adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional, face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes.
0362T	Behavior identification supporting assessment, each 15 minutes of technician time face-to-face with a patient, with the physician or other qualified healthcare professional on site and assistance of two or more technicians, for a patient exhibiting destructive behavior.

Behavioral health procedure codesHCPCS

H0031	Mental health assessment, by non-physician.
H0032	Mental health service plan development, by non-physician.
H2012	Behavioral health day treatment, per hour.
H2014	Skills training and development, per 15 minutes.
H2019	Therapeutic behavioral services, per 15 minutes.
H2021	Community-based wrap-around services, per 15 minutes.
H2027	Psychoeducational service, per 15 minutes; Pennsylvania only.

Diagnosis CodesICD-10

F84.0

Autistic disorder

Massachusetts Medicaid Early Intervention ABA limit

PopulationMassachusetts Medicaid Early Intervention members

Weekly ABA limitABA services should not exceed 30 hours per week

Effective dateOctober 1, 2021

Massachusetts BCBA supervision requirement

Supervised providerParaprofessional providing direct ABA services

Supervision ratio1 hour of BCBA supervision to 10 hours of direct service

Provider Actions and Documentation

Note

Verify Benefits and Applicable Mandates

Before making a coverage determination, verify the member's eligibility, member-specific benefit plan, and any applicable federal or state mandates. The member-specific benefit supersedes this guideline when benefits differ, services are excluded or limited, or a conflict exists.

Prior Authorization

Ohio Medicaid Telehealth and Authorization

For Ohio Medicaid members, ABA may be delivered through telehealth under current guidelines. Confirm provider Medicaid enrollment or obtain a single-case agreement, and verify applicable Ohio Medicaid practitioner eligibility and prior-authorization requirements.

Prior Authorization

Washington Inpatient ABA Requirements

For Washington Medicaid members, inpatient ABA requires the applicable WAC 182-531A criteria and an order from an ABA Center of Excellence provider. Document that less costly or less intrusive alternatives were unsuccessful or unavailable, measurable improvement is reasonably expected, severe harmful behavior prevents discharge, and treatment is short-term and focused to support discharge to a less restrictive setting.

Policy Background

Applied behavior analysis (ABA) is a scientific, systematic discipline that uses direct observation, measurement, functional analysis, and planned environmental modification to produce meaningful changes in behavior. When applied to autism spectrum disorder, ABA addresses core disorder-related deficits through structured interventions, objective progress measurement, and treatment decisions based on observed results. The policy states that ABA is well supported for children and adolescents up to age 21 with autism spectrum disorder; evidence for young adults and diagnoses other than autism spectrum disorder is more limited.

Definitions

Applied Behavior Analysis

DisciplineA scientific discipline among the helping professions

Primary focusAnalysis, design, implementation, and evaluation of social and other environmental modifications

MethodsDirect observation, measurement, and functional analysis of relations between environment and behavior

Autism spectrum disorder

Diagnostic frameworkAutism spectrum disorder is identified using DSM-5-TR criteria

Core targetABA targets the core deficits of autism spectrum disorder

Diagnostic standard

Level of Care Criteria

Inpatient ABA level-of-care criteria

Washington Medicaid inpatient ABA requires all of the following admission and continued-stay conditions.

Inpatient ABA level of care

Severe harmful behavior prevents discharge to a less restrictive setting.
Less costly and less intrusive interventions have failed, or no equally effective substantially less costly alternative is available.
A qualified ABA Center of Excellence provider orders treatment with a reasonable expectation of measurable improvement.
Treatment remains short-term and focused on stabilizing harmful behavior to promote discharge to a less restrictive setting.

Applied Behavior Analysis Criteria

Applied Behavior Analysis treatment criteria

ABA is covered when all general proven-condition criteria are met.

General ABA treatment conditions

The intervention is systematic and based on comprehensive applied behavior analysis principles.
The intervention targets autism spectrum disorder core deficits as outlined by DSM-5-TR.
The intervention is delivered in a clinically indicated home, center or office, or community setting.
The intervention is delivered by qualified and appropriately supervised personnel.
The intervention uses appropriate intensity, continuous measurement, and objective analysis of efficacy.

Treatment Modalities

Focused ABA

Focused ABA is medically necessary when all of the following apply.

Treatment is directed toward reducing dangerous or maladaptive behavior and strengthening appropriate functional behavior.
Treatment intensity is based on the individual's needs and response.

Comprehensive ABA

Comprehensive ABA is medically necessary when all of the following apply.

Treatment addresses broader developmental and behavioral needs.
Total intensity includes direct and indirect services, such as caregiver training and supervision.

Visit and Service Limits

Massachusetts Medicaid Early Intervention visit limit

Eligible populationMassachusetts Medicaid Early Intervention members

ServiceApplied behavior analysis services

Maximum30 hours per week

Policy Summary

PayerBlue Cross Complete of Michigan

PolicyApplied Behavior Analysis (ABA) Supplemental Clinical Criteria

Policy CodePolicy BH803ABASCC042023

Change TypeAnnual reviewno material change

Effective DateN/A

Last ReviewApr 18, 2023

Next Review DateApril 18, 2023

Key ActionObtain prior authorization before providing applied behavior analysis services.

SourceLink

On This Page

Care coordination and discharge planning occur at a frequency appropriate to the individual's needs and include providers who will receive the client after discharge.

ABA is provided at the least restrictive and most clinically appropriate level for the individual's needs.

ABA is medically necessary for reasons other than convenience and must be expected to produce therapeutic benefit.

Differential and co-occurring diagnoses are considered.

Medical, genetic, psychological, or communication assessment is completed when clinically indicated.

Qualified and appropriately supervised personnel deliver treatment.

The plan is updated based on objective progress and clinical need.

Symptom severity and progress relative to treatment duration are considered.

The treatment plan provides for reducing service intensity over time.

Home visitsThe direct service provider and supervisor may both need to be present during the home visit

Supported age range

Supported populationChildren and adolescents with autism spectrum disorder

Age rangeUp to age 21

Adult requestsTreatment requests for adults are clinically reviewed under the guidelines

Continued-treatment improvement settings

Expected outcomeClinically meaningful improvement in behavior and skill deficits

Minimum settingsAt least 2 settings

Applicable settingsHome, school, or community

Inadequate-progress review period

TriggerInadequate progress with targeted symptoms or behaviors, or no demonstrable progress

Review periodWithin 6 months

Required responseDocument the reasons and modify or change treatment interventions to attempt adequate progress

Discharge for absent progress

Discharge triggerNo clinically significant progress or measurable improvement

Minimum periodAt least 3 months

MeasuresAdaptive functioning, communication, language, or social skills

Coordinate care and discharge planning at the frequency required by the member's needs, including providers who will receive the member after discharge.
Continuation of ABA that began in another setting does not qualify for expedited prior authorization.

Prior Authorization

Prior Authorization Required

Obtain prior authorization before providing applied behavior analysis (ABA).

Documentation Required

Continued ABA Requires Updated Review

For each continued-treatment medical-necessity review, submit an updated treatment plan and progress reports demonstrating continued clinically meaningful improvement, objective measurement of each target, caregiver progress, and a plan to transition service intensity over time.

Documentation Required

Maintain the ABA Treatment Plan

Maintain an outcome-oriented ABA treatment plan that is continuously updated and includes baseline data, measurable goals, target behaviors, frequency, intensity, duration, projected timeframes, treatment setting, instructional methods, requested hours, and clinical justification.

Documentation Required

Document Clinical Necessity and Level of Care

Document clinical necessity and the least restrictive, most clinically appropriate level of care. Explain the functional impairments and target behaviors, expected measurable benefit, requested intensity and duration, and why the requested setting and hours are necessary.

Documentation Required

Maintain Provider Credentials

Maintain current certification, licensure, credentialing, and training records for each professional providing ABA. Identify the BCBA or qualified licensed clinician responsible for treatment and document direct supervision of paraprofessionals or other non-licensed staff.

Documentation Required

Washington Inpatient Documentation

For Washington inpatient ABA, document the qualifying diagnosis, ordering ABA Center of Excellence provider, failed or unavailable less costly alternatives, expected measurable improvement, severe harmful behavior preventing discharge, short-term stabilization purpose, and active discharge coordination.

Documentation Required

Validate the Diagnosis

Validate the ASD or other applicable mandated diagnosis through a documented comprehensive assessment by a clinician qualified under state licensure. Include DSM-5-TR diagnostic findings, current severity, functional impairment, developmental history, caregiver and family interviews, observations across settings, appropriate screening or assessment instruments, cognitive, adaptive, language, sensory and medical assessments, and differential or comorbid diagnosis considerations.

Do not rely on a single screening or diagnostic instrument as the definitive diagnosis.
Review prior records, behavioral interventions, family history, psychosocial information, and the individual's functioning in family, peer, school, and other settings.

Documentation Required

Treatment Plan Documentation Elements

The treatment plan must translate assessment findings into individualized, measurable goals and interventions. Document functional assessment results, target behaviors and deficits, replacement and skill-acquisition goals, baseline measures, projected timeframes, treatment setting, methods, requested hours, intensity, duration, and ongoing progress measurement.

Address social communication, social interaction, language, restricted or repetitive behavior, self-injury, aggression, destructive or other maladaptive behavior, and replacement skills as clinically appropriate.
Identify the credentialed ABA provider, supervision arrangement, and supervision responsive to client complexity, safety, barriers to progress, and transitions.
Coordinate goals with other professionals and document generalization and maintenance strategies.
Review or update the plan as clinically indicated, generally twice annually unless state mandate or clinical circumstances require a different schedule.

Documentation Required

Initial Authorization Documentation

For initial authorization, submit documentation sufficient to establish the diagnosis, medical necessity, requested services, provider qualifications, coordination of care, and caregiver participation.

Comprehensive diagnostic and functional assessments, including targeted risk behaviors.
Treatment plan with goals, baseline measures, requested setting, dates of service, total days per week, hours per day, duration, and clinical justification.
Types and frequency of other therapies, targeted behaviors or deficits, progress with existing services, and measurable discharge or continued-care criteria.
Licensure, certification, and credentials of all professionals providing ABA.
Evidence of caregiver engagement and compliance with recommendations.

Documentation Required

Coordination and Supporting Records

Submit records showing coordination with other service providers and agencies to reduce unnecessary duplication and support consistent treatment. Coordination records may include communications with daycare, preschool, school, early intervention, occupational, speech, physical, medical, behavioral health, and other allied providers.

Identify each therapy or service, frequency, targeted behaviors or deficits, and progress.
Document coordination attempts; attempts are acceptable when another provider will not collaborate.
Include applicable IEP, IFSP, early-intervention, preschool or special-education records when available.
Document the total requested ABA schedule, service location, dates of service, and measurable criteria for completing treatment and transitioning care after discharge.

Documentation Required

Coordination of Care and Caregiver Involvement

Document active caregiver involvement in the ABA program, including education, training, coaching, support, attendance, implementation of recommendations, and progress in managing behaviors and generalizing skills across settings.

Describe caregiver interventions and the individualized curriculum used to develop ABA implementation skills.
Record the percentage of planned caregiver sessions attended and any barriers to participation.
Document the plan for transitioning ABA interventions to parents or caregivers.
If a parent or guardian cannot participate, document the reason and an alternative plan for providing home-management skills.

Documentation Required

Continued-Treatment Documentation

For continued-treatment review, submit updated treatment plans and progress reports showing a reasonable expectation of clinically meaningful improvement in at least two settings, no persistent worsening, objective progress for each target using baseline-consistent measures, caregiver progress, and planned reduction or transition of service intensity.

Include validated adaptive-functioning assessments when used to evaluate progress.
Explain any failure to meet goals or absence of demonstrable progress.

Documentation Required

Address Insufficient Progress

When progress is inadequate or absent, document the clinical assessment and treatment modifications undertaken to restore adequate progress.

Consider increased time or frequency, changed treatment techniques, increased caregiver training, identification and resolution of barriers, evaluation of newly identified coexisting disorders, and modification or removal of goals.
Submit the reasons for inadequate progress and the resulting treatment-plan changes with the continued-treatment request.

Documentation Required

Diagnostic and Clinical Assessment Records

For each request, maintain the diagnostic and clinical assessment record supporting ABA, including the comprehensive ASD assessment, demographic information, developmental and educational history, functional behavioral assessment, targeted risk behaviors, and relevant medical and behavioral health history.

Include known conditions, prior treatment dates and providers, current treating clinicians, current interventions, and responses to treatment.
Document parent training, barriers to progress, and response to interventions.

Documentation Required

Treatment and Daily Progress Records

Maintain complete daily progress notes for every ABA service. Records must be legible and connect the service delivered to the authorized treatment plan and measurable goals.

Record place of service, start and stop times, rendering professional, specific service, attendees, interventions performed, and response or progress.
Identify whether the session involved direct treatment, supervision, caregiver or parent training, or another authorized service.

Documentation Required

Coordination and Supporting Records

Maintain all records supporting continuity, coordination, supervision, and nonduplication of care. Include coordination with school-related services, supervision of paraprofessionals, and available educational or allied-health records.

Retain IEP records when applicable and available.
Retain progress notes from early intervention, preschool, special education, speech, occupational, physical, medical, behavioral health, and other allied services when applicable and available.
Document coordination attempts when other providers will not collaborate.

Documentation Required

Initial Care Coordination and Caregiver Plan

Include coordination-of-care and caregiver-participation documentation with the initial authorization request. Show how ABA will be integrated with other services, how duplication will be avoided, and how caregivers will implement and generalize treatment strategies.

Document caregiver education, training, coaching, support, attendance, engagement, and follow-through.
Provide the caregiver transition plan and identify alternate supports when caregiver participation is not possible.

Documentation Required

Continued-Treatment Review Documentation

For each continued-treatment review, explain the member's response to treatment and continued need for ABA. Include objective progress toward each goal, current target behaviors, caregiver progress, treatment barriers, and planned changes in intensity or transition of services.

Document improvement in at least two settings when applicable.
Document that treatment is not persistently worsening symptoms or behaviors.
Use the same measurement methods used to establish baseline whenever possible.

Documentation Required

Insufficient-Progress Assessment and Modification

If targeted symptoms or behaviors show inadequate or no demonstrable progress, assess and document the reasons and modify the treatment plan. Continued authorization must explain why additional treatment is expected to achieve adequate progress.

Document increased time or frequency, changed techniques, increased caregiver training, resolved barriers, newly identified coexisting disorders, or reconsidered goals as applicable.

Denial Risk

Program Does Not Meet Proven ABA Conditions

Programs or interventions that do not satisfy all proven ABA conditions are considered unproven and may be denied.

The intervention must be systematic, based on comprehensive ABA principles, target core ASD deficits, use objective ongoing measurement, be delivered in an appropriate setting, and be provided by or under the required supervision of an appropriately trained professional.
ABA must be needed for clinical reasons rather than convenience and must produce expected therapeutic benefit.

Denial Risk

IDEA-Covered School Services

Services otherwise covered under the Individuals with Disabilities Education Act (IDEA), such as a one-to-one school aide, are not covered under this ABA benefit.

Coordination with school services, teacher training, meetings with school personnel, and observations may be included when otherwise eligible; the school service itself remains excluded.

Denial Risk

Convenience or Lack of Expected Benefit

ABA is not covered when requested primarily for the convenience of the individual, family, physician, or other parties, or when the record does not support expected therapeutic benefit.

Document clinical need, expected measurable outcomes, objective monitoring, and why ABA is the least restrictive and most clinically appropriate option.

Prior Authorization

Washington Inpatient Expedited Authorization

For Washington inpatient ABA, request expedited prior authorization only when the inpatient-specific criteria are met and the service is short-term, focused stabilization intended to permit discharge to a less restrictive setting.

Do not use expedited prior authorization for continuation of ongoing ABA that was provided in another setting before hospitalization.
Document the qualifying diagnosis, COE order, severe harmful behavior preventing discharge, failed or unavailable alternatives, expected measurable improvement, and discharge coordination.

Denial Risk

Services Outside Covered ABA Conditions

Services outside the covered ABA conditions may be denied, including interventions that do not target core ASD deficits, are not systematic ABA, are delivered by unqualified personnel, or are provided at an inappropriate level or setting.

Programs targeting mental disorders other than DSM-5-TR-defined ASD are unproven under this policy unless applicable state-mandated coverage provides otherwise.
Document objective measurement, ongoing analysis, appropriate intensity, and least restrictive clinically appropriate delivery.

Denial Risk

Avoid Duplicative Services

ABA must not duplicate services provided to or available to the member through other medical, behavioral health, educational, or allied-health services.

Compare ABA with individual, group, or family therapy; occupational therapy; speech therapy; school services; and other active interventions.
Document coordination, distinct targets, frequencies, progress, and the clinical rationale for any concurrent services.

Note

Adult Requests Require Clinical Review

Treatment requests for adults require clinical review because evidence for young adult populations and diagnoses other than ASD is limited.

Submit individualized documentation of diagnosis, functional impairment, clinical necessity, expected measurable benefit, treatment goals, and the requested intensity and duration.

Denial Risk

Insufficient Progress or Worsening

Continuation may be unsupported when treatment produces insufficient progress, no demonstrable progress, or persistent worsening of symptoms or behaviors.

Document the progress assessment, reasons for inadequate response, modifications attempted, caregiver participation, and why further ABA is reasonably expected to produce clinically meaningful improvement.

Denial Risk

Discharge Criteria

Further ABA services are not covered when discharge criteria are met, including achievement of goals or maximum benefit, no clinically significant progress or measurable improvement for at least three months, persistent worsening, unlikely long-term benefit, or refusal or inability to participate that compromises effectiveness.

Assess adaptive functioning, communication, language, and social skills when determining measurable progress.
Document discharge planning and transition of care.

Denial Risk

Demonstrate Continued Medical Necessity

Failure to demonstrate continued medical necessity may result in nonauthorization of additional ABA. Each continued request must show ongoing clinically meaningful benefit, objective progress, active caregiver participation, and a clinically justified plan for continued or reduced services.

Submit updated treatment and progress records for each review.
Explain barriers, treatment changes, and expected outcomes when progress is limited.

The applicable deficits are those outlined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision

Applied Behavior Analysis intervention

ApproachA systematic intervention based on the principles of comprehensive applied behavior analysis

Primary targetThe core deficits of autism spectrum disorder

Clinical purposeIntervention is delivered to address autism spectrum disorder-related deficits through applied behavior analysis principles

Assistant or paraprofessional ABA provider

Qualified individualA Board-Certified Assistant Behavior Analyst or non-licensed individual

Permitted functionsAssists in assessment of deficits or adaptive behaviors, or implements the treatment plan

SupervisionWorks under the direct supervision of a BCBA or licensed behavioral health clinician who developed the treatment plan and takes responsibility for the member's care

Focused ABA

Primary purposeReduce dangerous or maladaptive behavior

Skill focusStrengthen more appropriate functional behavior

Use in developmentOften more appropriate for older children or adolescents than comprehensive treatment

Comprehensive ABA

Developmental timingGenerally rendered earlier in development

ScopeEncompasses broader treatment needs

IntensityDetermined by the individual's clinical needs and response

Autism spectrum disorder severity levels

Level 1 — Requiring supportNoticeable social-communication impairment and restricted or repetitive behaviors causing significant interference in one or more contexts

Level 2 — Requiring substantial supportMarked social-communication deficits and restricted or repetitive behaviors that interfere with functioning in a variety of contexts

Level 3 — Requiring very substantial supportSevere social-communication deficits and restricted or repetitive behaviors that markedly interfere with functioning in all spheres

Care coordination and discharge planning occur at a frequency appropriate to the individual's needs and include receiving providers.

Outpatient ABA level-of-care criteria

Outpatient ABA is supported when the required assessment, ongoing benefit, participation, and transition criteria are met.

Outpatient ABA level of care

A comprehensive autism diagnostic assessment, developmental and educational history, functional behavioral assessment, treatment history, measurable targets, and treatment plan are documented.
There is a reasonable expectation of clinically meaningful improvement in at least two settings.
There is no persistent worsening, and progress is documented using baseline methods and validated adaptive-functioning measures.
Caregivers participate and progress in behavioral interventions.
The treatment plan includes transition of intensity over time.

Outpatient discharge condition

Goals are achieved or maximum benefit is reached.
There is no clinically significant progress or measurable improvement for at least three months.
Treatment persistently worsens deficits or behaviors.
The child is unlikely to benefit or maintain long-term gains.
Caregiver participation or adherence is insufficient to support effectiveness.

ABA is provided at the least restrictive and most clinically appropriate level.

ABA is needed for a therapeutic purpose rather than convenience.

Massachusetts Medicaid Early Intervention requirements

For Massachusetts Medicaid Early Intervention members, the following service and supervision requirements apply.

Massachusetts Early Intervention ABA

ABA services do not exceed 30 hours per week.30 hours per week
BCBA supervision of a paraprofessional is provided at a ratio of one hour of supervision to ten hours of direct service.1:10

The direct service provider and supervisor may be required to be present together during a home visit.

ABA treatment criteria

ABA is medically necessary when the following treatment-specific requirements are met.

ABA treatment requirements

ABA targets autism spectrum disorder core deficits or associated maladaptive behaviors.
Interventions are systematic, objective, and measurable.
Treatment is delivered by qualified and supervised personnel.
Treatment is provided at the least restrictive clinically appropriate level.
Caregivers participate in and receive training.
Treatment is coordinated with other providers and settings and does not duplicate other services.
Ongoing progress is demonstrated, or barriers are clinically addressed through a justified plan to modify treatment.

Continued ABA criteria

Continued ABA services require updated evidence of medical necessity.

Ongoing ABA medical necessity

Clinically meaningful improvement is expected in behavior and skill deficits in at least two settings.At least 2 settings
Symptoms or behaviors are not persistently worsened by treatment.
Progress for each targeted symptom and behavior is measured and documented using baseline-consistent methods.
Caregivers are involved and developing intervention skills.
Service intensity is planned to transition over time.

ABA continued-treatment criteria

ABA continuation and treatment planning require documented clinical benefit, caregiver participation, measurable progress, and transition planning.

The child is expected to improve meaningfully in at least two settings.At least 2 settings
Treatment is not persistently worsening symptoms or behaviors.
Each target is measured against baseline, including use of validated adaptive-functioning assessments.
Caregivers participate and progress in behavioral interventions.
Service intensity is planned to decrease over time.

Response to treatment status

If progress is inadequate or absent, document the reasons and modify treatment.
If goals are achieved, establish clinically relevant new goals or transition to less intensive care.

Intensity is determined by the individual's clinical needs and response.

Intensive behavioral therapy / ABA

Intensive behavioral therapy and ABA must use an established treatment methodology.

Intensive behavioral therapy: Treatment methodologies used as part of intensive behavioral therapies are established by the National Autism Center Standards Project.