CurrentCignaPolicy N/A

Applied Behavior Analysis (ABA) prior authorization and documentation requirements

Defines prior authorization requirements and required supporting documentation for ABA services (assessment and treatment) for Evernorth Behavioral Health; applies to providers requesting ABA coverage and network exceptions for Cigna members.

Policy Summary

PayerCigna

PolicyApplied Behavior Analysis (ABA) prior authorization and documentation requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with a fully completed standardized ABA assessment and detailed treatment plan including quantitative goal data.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97155 monthlyMonthly auth code

assessment codes no PAAssessment codes PA

4.33Monthly calc

60 daysInitial assessment window

>=60 daysBreak requiring reassessment

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Medical Necessity and Coverage Criteria

Medical necessity core criteria

Medical necessity depends on a complete standardized assessment and a documented treatment plan meeting ALL of the following:

Assessment requirements: Include a fully completed standardized ABA assessment covering all clinical domains, readministered at least annually; for initial requests, completed within 60 days of the requested start date; include date of completion, respondent, and form/version used; grid/tower bubbles must indicate domain assessment or include clarifying comment.

Assessments that do not meet this standard (e.g., AFLS, EFL, PEAK PCA) are insufficient on their own to demonstrate medical necessity.

Treatment plan and settings: Describe how direct treatment time will be used in each setting where ABA occurs, including proximity of staff providing direct treatment, nature/description of active intervention, hours per week or month in each setting, frequency of learning opportunities, description of presentation method, clinical rationale for interventions in each setting, goal data and progress updates for each setting, and parent/caregiver training goals.

Goals and data: Provide quantitative baseline, interim, and current goal data with dates and clear, measurable mastery criteria aligned to reported data; goals must clearly relate to autism core deficits (social communication, social interaction, restrictive/repetitive behaviors).

Continuation / adjustments criteria

Requests for additional hours, to address barriers, or after a treatment break are covered when ALL of the following are provided:

Additional hours: Clinical rationale for the requested increase in treatment intensity, including description of new goals, behaviors, or assessment updates supporting the increase.

Refer to coverage policy for examples and page references.

Barriers to progress: Clinical rationale describing the pattern of limited progress or regression and a specific plan to address identified barriers to progress.

Refer to coverage policy pages 7 and 16 for guidance.

Break in treatment: If the break in treatment is 60 days or longer, submit updated quantifiable baseline data with dates and a new, fully completed standardized ABA assessment.>= 60 days

Refer to coverage policy page 7.

The following assessment tools alone do not meet the policy's standardized assessment standard and therefore are insufficient by themselves to demonstrate medical necessity for ABA services: Assessment of Functional Living Skills (AFLS), Essential for Living (EFL), and PEAK Relational Training System - PEAK Comprehensive Assessment (PCA). These instruments may be useful to inform treatment planning and case conceptualization, but the policy requires a fully completed standardized ABA assessment that covers all clinical domains, documents the date, respondent, and form/version, and is readministered at least annually (and within 60 days for initial requests).

Codes, Billing Rules, and Visit Limits

Covered ABA treatment and supervision CPT codesCPTCovered

97155	BCBA direct supervision / 1:1 treatment by BCBA (used for monthly authorization)
97153	Behavior technician direct 1:1 treatment
97154	Group behavior technician treatment
97156	BCBA assessment code (listed)
97157	BCBA service code (listed)
97158	BCBA service code (listed)
0373T	Adaptive behavior treatment with protocol modification

Assessment CPT codes (standard requests do not require prior authorization)CPT

97151	Behavior identification assessment, administered by BCBA
97152	Behavior identification supporting assessment by technician
0362T	Autism assessment code (listed as assessment)

Diagnosis codes mentionedICD-10

F84.0

Autism spectrum disorder

inv-07: Monthly hours calculation — weekly hours multiplied by 4.33

Monthly calculationMultiply weekly ABA hours by 4.33 to determine monthly averages.

ApplicationUse when converting requested weekly hours on the prior authorization form to the monthly authorization amount.

Authorization basisAuthorizations for treatment are written per month with CPT code 97155 (can be interchanged with 97153-97158 and 0373T).

inv-08: Break in treatment requiring reassessment (>= 60 days)

Break threshold>= 60 days — a break in treatment of 60 days or longer requires reassessment.

Required materials after breakProvide updated quantifiable baseline data with dates and a new, fully completed standardized ABA assessment.

Policy referenceRefer to page 7 of the coverage policy for additional information.

inv-19: ABA treatment (CPT 97155 interchangeable with 97153-97158 and 0373T) — authorization issued per month

Authorization cadenceAuthorizations for ABA treatment are issued per month using CPT code 97155.

Interchangeable codesCPT 97155 may be interchanged with ongoing treatment codes 97153–97158 and 0373T for billing/authorization purposes.

Billing noteWhen approved, monthly authorizations reflect the monthly average derived from weekly hours (weekly hours × 4.33).

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for ABA level of care and for network exception requests. ABA assessment CPT codes (97151, 97152, 0362T) do not require prior authorization for standard requests; network exception requests for assessments must use the exception form. Complete the Evernorth prior authorization request form and submit with supporting clinical documentation to ABA@Evernorth.com or fax to 860.687.9230. If approved, authorizations are written per month using CPT 97155 and may be interchanged with ongoing treatment codes 97153-97158 and 0373T. Requested ABA hours per week are multiplied by 4.33 to determine monthly averages.

Submit completed form and all supporting clinical documentation.
For network exception assessment requests, include assessment CPT (97151, 97152, 0362T) and completed exception form.
Send requests to ABA@Evernorth.com (preferred) or fax 860.687.9230; contact Autism Care Coordinator at 877.279.7603 for help.

Note

Provider-Facing Submission Highlight

Verify member coverage before submission and complete all sections of the prior authorization form clearly (typed responses preferred). Omissions, illegibility, or generalities may cause the request to be returned.

Evernorth assumes no responsibility for protection of electronic transmission prior to receipt — take necessary precautions.

Documentation Required

Required Supporting Clinical Documentation — Standardized Assessments

Provide a complete, standardized ABA assessment and attach it to the request. Include assessment date, respondent, form/version, and ensure all clinical domains are assessed. For initial requests, assessments should be completed within 60 days of the requested start date. Assessments that do not meet the standard (for example AFLS, EFL, PEAK PCA alone) are insufficient to demonstrate medical necessity.

Readminister standardized ABA assessment at least annually.
If assessment uses grids/bubbles, complete bubbles or add clarifying comments.
Refer to the coverage policy for acceptable assessment standards.

Documentation Required

Required Supporting Clinical Documentation — Treatment Across Settings

For each setting where ABA treatment will occur, include a clear description of how direct treatment time will be used, including proximity of staff, nature of intervention, hours per week/month, frequency of learning opportunities, how opportunities are presented, rationale for interventions, goal data and progress, and parent/caregiver training goals.

Provide setting-specific hours that align with the ABA treatment plan.
Include clinical rationale and progress data for each setting.

Documentation Required

Required Supporting Clinical Documentation — Goals and Data

Include quantitative treatment goal data (baseline, interim, current) with dates, and measurable mastery criteria for each goal. Goals should specify context/condition, clear behavior definitions, measurement methods, and independence criteria (e.g., 80% across sessions).

Ensure reported data align with mastery criteria.
Include dates for baseline and interim measurements.

Prior Authorization

Requirements for Increases and Breaks in Treatment

When requesting additional hours for an existing authorization, provide a clear clinical rationale for increased intensity (new goals, new behaviors, updated assessments, etc.). If there has been limited progress or regression, include rationale and a plan to address barriers to progress.

Document specific clinical changes driving the increase request.
Include barrier analysis and planned interventions.

Prior Authorization

Requirements for Breaks in Treatment

If there is a break in treatment of 60 days or longer, submit updated quantifiable baseline data with dates and a new, fully completed standardized assessment with the request for reauthorization.

Breaks >= 60 days require new assessment and baseline data before services resume.
Refer to coverage policy for additional detail.

Denial Risk

Documentation Quality and Completeness Risks

Avoid incomplete or low-quality documentation. Incomplete assessments, missing dates, lack of quantitative goal data, unclear setting descriptions, or missing rationale for increased hours can lead to returned or denied requests.

Typed, legible, and complete submissions reduce delay.
Ensure requested treatment hours match the ABA treatment plan.

Background and Scope

Applied Behavior Analysis (ABA) services are provided to address functional deficits commonly associated with autism spectrum disorder and require a standardized, comprehensive approach to assessment and treatment. Medical necessity is based on a fully completed standardized ABA assessment covering all clinical domains (including date, respondent, and form/version) that is readministered at least annually and completed within 60 days of the requested start date for initial requests.

Treatment plans must link goals to autism core deficits (social communication, interaction, and restrictive/repetitive behaviors) and include quantitative baseline, interim, and current goal data with measurable mastery criteria. Plans should describe how direct treatment time will be used in each setting (clinic, home, school, community, telehealth), specifying staff proximity, nature of the intervention, hours, frequency of learning opportunities, presentation method, clinical rationale, and caregiver training goals.

Progress must be documented with quantitative goal data; requests for increased hours, addressing barriers, or after a break in treatment require additional clinical rationale and documentation (including a new fully completed standardized assessment and updated baseline data if the break is >= 60 days).

ABA-Specific Clinical Criteria

ABA clinical criteria — documentation must demonstrate required elements

Documentation submitted must demonstrate the following elements:

Standardized assessment details: A fully completed standardized ABA assessment that assesses all clinical domains, includes date, respondent, and form/version, readministered at least annually, and for initial requests completed within 60 days of requested start date.

If grid/tower bubbles are used, complete applicable bubbles or add clarifying comments.

Setting-specific treatment description: For each setting where treatment occurs, document staff proximity, the nature and description of active intervention, hours per week/month in that setting, frequency of learning opportunities, how opportunities are presented, clinical rationale for interventions, and goal data for that setting.

Include parent/caregiver training goals for relevant stakeholders.

Goals and measurable data: Quantitative baseline, interim, and current goal data with dates and measurable mastery criteria for each goal; reported data must align with mastery criteria and relate to autism core deficits.

Be familiar with elements of a measurable goal (context, clear behavior definition, measurement method, mastery threshold).

OpenPayer

Applied Behavior Analysis (ABA) prior authorization and documentation requirements

Medical Necessity and Coverage Criteria

Codes, Billing Rules, and Visit Limits

Prior Authorization, Documentation, and Provider Responsibilities

Background and Scope

Assessment and Documentation Definitions

Level of Care — Outpatient / ABA Treatment

ABA-Specific Clinical Criteria

Direct Treatment and Supervision

Policy Revision History