Defines medical necessity criteria, assessment, and treatment requirements for Applied Behavior Analysis (ABA)/Intensive Behavioral Interventions for individuals with Autism Spectrum Disorder (ASD) for Cigna-administered benefit plans.
Change TypeFocused review — no clinical policy statement changes
Effective DateMay 15, 2026
Next Review DateDec 15, 2026
Key ActionSubmit prior authorization with a comprehensive ABA assessment (completed within 60 days), baseline quantitative data, and an individualized treatment plan specifying direct ABA hours/week and supervision details.
No material clinical or coverage changes in this revision.
ComprehensiveAssessment requirement
60 daysAssessment timing
F84.0-F84.9Accepted diagnosis codes
60 daysData window
AffirmingNeurodiversity approach
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5Revision events
Coverage Criteria for ABA / Intensive Behavioral Interventions
inv-01: Assessment Medical Necessity
Assessment for ABA is medically necessary when ALL of the following are met
Assessment necessity: Confirmed diagnosis of ASD (ICD-10 F84.0-F84.9 except F84.2) by a licensed independent practitioner with name/credentials/date provided; assessment performed by BCBA/LBA or licensed clinician trained in ABA; comprehensive assessment includes a reliable, valid, standardized instrument completed in entirety, with established reliability/validity for the population, administered by trained individual, current edition, date of administration and respondent recorded; assessment informs individualized treatment goals
Supports initiation of ABA assessment services
inv-02: Initiation of Treatment Medical Necessity
ABA treatment is medically necessary when ALL of the following are met
Diagnosis: Confirmed ASD diagnosis (ICD-10 F84.0-F84.9 except F84.2) by licensed independent practitioner with name/credentials and date provided
See Diagnosis requirements
Assessment recency and findings: Comprehensive ABA assessment completed within 60 days prior to start of treatment; standardized scores and scoring tables provided when applicable; results indicate deficits in DSM-5-TR ASD domains and correspond to proposed goals60 days
If assessment completed by other professional must document collaboration and that results reflect current functioning
Treatment plan: Individualized plan of care with clearly defined, measurable, developmentally appropriate goals directly related to ASD symptoms; quantitative baseline data for all targeted behaviors collected within 60 days prior to treatment; mastery criteria and methods of measurement specified
Includes group-treatment specifications if applicable
Treatment intensity and supervision: Planned intensity reflects severity and goals; supervision by BCBA/LBA or licensed clinician trained in ABA with direct supervision and indirect supervision consistent with 1-2 hours per 10 hours of direct treatment; supervisory services align with CPT descriptions; name and credentials of supervisor documented
Name and credentials of supervisor must be documented
inv-03: Continued Treatment Criteria
Continued treatment with ABA is considered medically necessary when ALL of the following are met:
Continued Treatment Preconditions: Initiation criteria were met at treatment initiation; ALL initiation criteria are currently met; treatment plan/plan of care has been updated to address current deficits, behaviors, and progress; quantitative baseline/interim/current data with collection dates are provided for all behaviors and skills; current data collected within 60 days prior to start date and within 60 days prior to authorization request; data indicate ongoing and sustained progress toward mastery; evidence of measurable/maintained improvement via reliable standardized assessment within one year; if improvement not demonstrated, barriers identified with documented plan and protocol modifications; new proposed interventions include baseline data collected within 60 days prior to implementation; standardized assessment required after any break >60 days.see node text
inv-04: Other Factors and Severe Behavior Program Criteria
Conditions under which multiple providers, feeding/toileting goals, and Severe Behavior Programs are medically necessary:
Multiple ABA Providers: All ABA services delivered by multiple organizations during the same authorization period are only medically necessary if there is (a) a clear plan to coordinate care and avoid duplication, (b) consistent and non-contradictory strategies across providers, and (c) combined planned intensity that reflects severity and clinical needs.
From 'Other Factors'
Feeding and Toileting Goals: When treatment goals include feeding/toileting, the plan must include specific safety measures/protocols and documented consultation with medical and/or dietary/nutritional professionals prior to initiation and ongoing documentation of consultation.
From 'Other Factors'
Severe Behavior Program Requirements: For Severe Behavior Programs, initiation and continued treatment criteria must be met plus: complete treatment history including comorbidities and prior higher levels of care; complete history of targeted severe behaviors (e.g., emergency services, bodily injury, property destruction); documented response to prior/current treatment showing necessity; assessment administered by requesting or another provider within 60 days prior to start; quantitative baseline/interim/current data within 60 days prior to start and meeting the Glossary definition of Severe Behavior; documented safety measures and medical/mental health consultation prior to initiation and ongoing.
inv-05: Individualization, Scope, Intensity, and Supervision Requirements
Covered when ABA services meet individualized, data-driven criteria and are delivered in medically necessary settings and intensity:
Overall: Services are individualized based on multimodal assessments (record review, interview, direct observation, functional behavior assessment, skills-based and standardized assessments) and documented in a treatment plan with measurable goals and transition planning.
See assessment and treatment planning sections
Scope and Goals: Scope (focused vs comprehensive) aligns with the number and complexity of goals; treatment objectives and settings are specified in the plan.
Focused = limited domains; comprehensive = many domains
Intensity (direct ABA hours/week) is determined by clinical need and data; case supervision hours tied to direct treatment and adjusted per individual needs (e.g., rapid progress, barriers, severe behavior).
Intensity excludes supervision, caregiver training from direct hours
This policy includes a state-specific limitation: Virginia fully insured business is not subject to this coverage policy. Refer to the applicable benefit plan document for state-mandated terms, conditions, and limitations of coverage.
The policy specifies certain services that are not covered or reimbursable, including intensive behavioral interventions other than ABA and services that are primarily educational or vocational in nature. It also states that provision of ABA delivered to the same individual at the same time as another treatment modality (for example, ABA and speech therapy or ABA and occupational therapy) is not covered.
While the policy does not list explicit coverage exclusions for ABA when used to treat ASD, it includes statements disavowing vaccine–autism causal claims by citing professional guidance (AACAP, AAP) that vaccines are not causally associated with ASD and vaccination recommendations remain unchanged.
The document notes that ABA for conditions other than ASD (for example, Down syndrome, learning disabilities, ADHD) is considered unproven due to a lack of scientific evidence, and the role of ABA in these conditions is not established.
In the cited revision and surrounding content there are no additional explicit coverage exclusions stated beyond those already specified in the policy excerpts.
The policy requires documentation that ABA services are not used to replace or replicate responsibilities of the setting/environment (for example, classroom aide, 1:1 teacher, tutor, vocational assistant/coach, respite). Providers must identify and document that services meet the definition of direct treatment and align with treatment plan goals rather than substituting for setting responsibilities.
The policy states that Applied Behavior Analysis (ABA) is considered not medically necessary for all non‑autism spectrum disorder (ASD) indications, explicitly including Rett syndrome as an example of a non‑ASD condition for which ABA is not medically necessary.
Within this section there are no explicitly listed items beyond the glossary and definitional material referenced; no additional 'not medically necessary' entries are provided in these chunks.
The reviewed revision notes and related chunks do not contain explicit statements declaring additional services as 'not medically necessary' in these excerpts.
Coding and Assessment Timing
Covered diagnosis codes for ABA eligibilityICD-10Covered
Considered Medically Necessary when criteria metCPTCovered
97151
Behavior identification assessment, each 15 minutes
97152
Behavior identification-supporting assessment, technician, each 15 minutes
97153
Adaptive behavior treatment by protocol, technician, face-to-face one patient, each 15 minutes
97154
Group adaptive behavior treatment by protocol, technician, face-to-face two or more patients, each 15 minutes
97155
Adaptive behavior treatment with protocol modification, clinician, each 15 minutes
97156
Family adaptive behavior treatment guidance, clinician, each 15 minutes
97157
Multiple-family group adaptive behavior treatment guidance, clinician, each 15 minutes
Considered Medically Necessary when criteria met (group/severe behavior-specific codes)CPT | HCPCSCovered
97158
Group adaptive behavior treatment with protocol modification, clinician, each 15 minutes
0362T
Behavior identification supporting assessment, technicians' time, each 15 minutes (specific destructive behavior components)
0373T
Adaptive behavior treatment with protocol modification, technicians' time, each 15 minutes (specific destructive behavior components)
inv-18: Assessment recency — assessment instrument and baseline data must be completed within 60 days prior to treatment start
RequirementAssessment instrument administration must be completed within 60 days prior to the start of treatment.
Baseline dataQuantitative baseline data for all targeted behaviors must be collected within 60 days prior to the start of treatment.
Assessor qualificationsAssessment must be performed by a BCBA®, LBA, or an independently licensed mental health clinician with documented ABA training.
inv-19: Current Data collection window — current data must be collected within no more than 60 days prior to continued treatment or authorization
Current data windowCurrent quantitative data must be collected within no more than 60 days prior to the start date of the continued treatment request.
Provider Requirements, Authorization, and Documentation
Prior Authorization
Prior Authorization: Assessment and Data Requirements
Prior authorization: A full and comprehensive ABA assessment is required for authorization. The assessment must be performed by a BCBA®, LBA, or a licensed independent mental health clinician with documented ABA training, and include all Assessment criteria. Standardized scores/tables or scoring grids must be provided when applicable. Administration of the assessment instrument must be completed within 60 days prior to the start of treatment. Quantitative baseline data for all behaviors and skills targeted for intervention must be collected and provided with collection dates, and these baseline data must be obtained within 60 days prior to the start of treatment. If the assessment was completed by another professional, the requesting provider must document collaboration and confirm the results reflect current functioning.
Assessment by BCBA®, LBA, or licensed independent clinician with documented ABA training
Standardized scores/score tables or scoring grids provided when applicable
Assessment administered within 60 days prior to treatment start
Quantitative baseline data for all targeted behaviors/skills with dates (within 60 days prior to start)
If assessment by another professional: documented collaboration and confirmation of current functioning
Background and Rationale
Intensive Behavioral Interventions (IBI), including Applied Behavior Analysis (ABA), apply behavior-analytic principles to improve socially significant behaviors by systematically identifying variables responsible for behavior change and using experimentation to demonstrate intervention effects. ABA targets domains consistent with ASD diagnostic criteria such as social communication, social interaction, and restricted/repetitive behaviors, and emphasizes individualized assessment, measurable goals, ongoing data collection, and objective analysis to inform treatment.
Definitions and Credentialing
inv-42: ABA / Applied Behavior Analysis definition — high-level definition
DefinitionApplied Behavior Analysis (ABA) is the science in which tactics derived from the principles of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change.
ScopeIncludes intensive behavioral interventions (IBI) and adaptive behavior treatment as components of ABA delivered to improve social communication, interaction, and reduce restrictive/repetitive behaviors.
GoalInterventions aim to develop new skills and reduce behaviors that interfere with learning or daily functioning, informed by objective assessment and data analysis.
Admission to Outpatient / Intensive Behavioral Intervention: Meets diagnostic, assessment, treatment plan, baseline data, and supervision requirements as specified in initiation criteria
Outpatient/intensive behavioral intervention level admission requires same initiation criteria
Continued Stay: Ongoing analysis and data-informed decision-making demonstrating progress or documented barriers; periodic reporting of interim and current data within no more than 60 days prior to authorization request when treatment initiated earlier60 days
Quantitative data must be provided separately by setting when applicable
inv-52: Severe Behavior Program / Intensive ABA
ABA Program, Service, and Training Criteria
inv-55: ABA behavioral health criteria
Behavioral health-specific criteria for ABA assessment and treatment
Diagnostic confirmation: ASD diagnosis per DSM-5-TR with documentation of diagnosing provider credentials and date
Required for ABA services
Comprehensive assessment: Assessment by BCBA/LBA or licensed clinician trained in ABA using standardized instruments with established reliability/validity and full administration; assessment results must map to treatment goals
See assessment instrument specifications
Data-driven treatment planning: Baseline quantitative data within 60 days, measurable goals with mastery criteria, plan for generalization and discharge/fading services, stakeholder training and documented supervision
Includes stakeholder training requirements and supervision ratio guidance
Permitted Treatment Modalities and Programs
inv-59: ABA / Intensive Behavioral Intervention
Modality - ABA / Intensive Behavioral Intervention: Direct ABA services must meet the ABA definition and be delivered with direct engagement and line-of-sight (unless telehealth) and align with treatment plan goals; services for behavior reduction require data demonstrating frequency/severity warranting direct intervention.
inv-60: ABA (direct treatment, stakeholder training, supervision)
Delivery Components: ABA delivery includes direct treatment, stakeholder training, and supervision; documentation must specify which component is provided and align with CPT descriptions and the individualized plan of care.
inv-61: Telehealth / In-person / Hybrid
Modality Selection:
Intensity, Visit Limits, and Requests for Increased Intensity
inv-64: Requests for increased intensity must include rationale, data showing how increased intensity would improve outcomes, and data describing intended use of increased intensity.
Required elements for intensity increaseRequests for increased treatment intensity must include description and clinical rationale, documented quantitative evidence showing how increased intensity would improve outcomes, and data describing how the additional intensity would be utilized.
Data expectationsProvide quantitative data demonstrating expected benefit and how increased hours will be applied to specific goals; include dates of data collection.
ContextualizationRequests must also align with updated treatment plan/plan of care and indicate how increased intensity fits within individualized treatment needs.
inv-65: No explicit numeric visit limits specified; intensity is individualized and expressed as direct ABA hours/week.
No numeric limitsThe policy specifies no explicit numeric visit limits; intensity is individualized and defined as direct ABA treatment hours per week.
Change TypeFocused review — no clinical policy statement changes
Effective DateMay 15, 2026
Next Review DateDec 15, 2026
Key ActionSubmit prior authorization with a comprehensive ABA assessment (completed within 60 days), baseline quantitative data, and an individualized treatment plan specifying direct ABA hours/week and supervision details.
Settings: Services are deliverable in any medically necessary setting relevant to goals (home, school, clinic, community, residential, RTC, vocational, transportation).
Setting selection based on environmental variables necessary for goals
Severe Behavior: Individuals with severe behavior may require short-term focused intensive programs, higher staff-to-client ratios, and increased case supervision, especially during assessment and early treatment stages.
May necessitate specialized intensive-outpatient, day-treatment, residential or in‑individual programs
Authorization timingCurrent data must also be collected within no more than 60 days prior to the date the authorization request is received, with collection dates reported.
Separate setting reportingWhen treatment occurs across multiple settings, quantitative data must be obtained and reported separately by location with dates.
Prior Authorization
Prior Authorization and Continued Treatment Requirements
Prior authorization and continuation requests must demonstrate that initiation criteria were met at treatment start and that initiation elements are currently being adhered to. Continued treatment requests must include updated treatment plans reflecting current deficits and progress, quantitative baseline, interim and current data with collection dates, and evidence that current data were collected within no more than 60 days prior to the continued-treatment start date and prior to the authorization request. When requesting increased intensity, include a clinical rationale, quantitative evidence that the increase will improve outcomes, and description of how increased intensity will be used.
Documentation that initiation criteria were met at treatment initiation
Updated treatment plan addressing current deficits and progress
Baseline, interim, and current data with dates for targeted behaviors/skills across settings
Current data collected within 60 days of continued-treatment start and authorization request
If increasing intensity: clinical rationale, supporting quantitative data, and utilization plan
Prior Authorization
Authorization Must Reflect Intensity and Setting
Authorization must reflect the individualized intensity, staffing, and setting required to safely and effectively deliver ABA services. Requests should specify the number of direct ABA treatment hours per week (dosage), the staffing model (e.g., RBT®, BCaBA®, BCBA® supervision ratio), and supervision frequency sufficient to the intensity of services. The requested authorization must align with the treatment plan, identified goals, and documented data supporting the selected intensity and setting(s).
Authorization must specify direct ABA hours per week (exclusive of supervision and stakeholder training)
Document staffing ratios and supervision frequency tied to clinical needs
Authorization must align to individualized treatment plan, goals, and supporting data
Settings to be specified (home, school, clinic, community, residential, etc.)
Note
Retrospective Authorization Timing
Retrospective authorization requests are those submitted more than 90 days after the start date of the requested authorization or any time after patient discharge. Such requests are treated as retrospective and are subject to the rules governing retrospective authorizations.
Any authorization request made when >90 days have passed since the requested start date is retrospective
Requests after discharge are retrospective
Denial Risk
No Specific Denial Triggers Specified
No specific denial triggers beyond standard documentation and coverage requirements are enumerated in this section. Providers should be aware that claims submitted without covered codes will be denied as not covered, and services lacking required documentation, assessment, or data may be determined not medically necessary.
Claims without covered codes will be denied as not covered
Lack of required assessments, baseline/interim/current data, or documentation may result in denial as not medically necessary
Documentation Required
Clinical Documentation Requirements
Clinical documentation expectations: maintain a separate written record for each billed CPT® service that includes start/end date and time, location, focus of service, detailed description of interventions provided, individuals present, specific service delivered (direct, supervision, stakeholder training, etc.), and the name, credential, and signature of the ABA provider. Documentation must support billed services and link to the treatment plan and data.
Separate written record per billed CPT® code
Start and end date/time for each service
Location and focus of service
Detailed description of intervention provided and individuals present
Service type (direct, supervision, stakeholder training) and provider name/credential/signature
Documentation Required
Required Clinical Documentation
Required clinical documentation for authorization and continued care includes comprehensive assessments (FBA, skills-based, and standardized assessments), clearly linked treatment plans with measurable goals and mastery criteria, quantitative baseline/interim/current data with dates for all targeted behaviors and stakeholder training (separated by setting when applicable), supervision and stakeholder training documentation (provider names/credentials), and documentation of coordination when multiple ABA providers are involved.
Functional Behavior Assessment (FBA) and skills-based assessments as applicable
Standardized assessment results with scores/tables and dates
Treatment plan with measurable goals, objectives, and mastery criteria
Quantitative baseline/interim/current data with collection dates, separated by setting/location
Documentation of supervision: name and credentials of supervisor and supervision frequency
Stakeholder training records: trainer name/credentials, measurable goals, mastery criteria, and data
Note
Individualized Intensity and Scope
Individualize scope and intensity of treatment based on assessment results, response to treatment, caregiver circumstances, and target behavior characteristics. Scope ranges from focused (limited domains) to comprehensive (many domains across settings); intensity (hours/week) should be medically necessary and supported by data from multidimensional assessment.
Scope: focused versus comprehensive treatment determined by assessments and response to treatment
Intensity: specify medically necessary direct treatment hours per week, justified by data
Consider caregiver ability, setting-specific needs, and resources when individualizing plan
Note
Evidence-Informed Selection
Select interventions and program elements informed by the evidence base and the individual's needs. The strength of evidence varies by intervention intensity and target; choose evidence-informed modalities, justify selections with available literature and individual data, and adjust programs based on regular data analysis and outcomes.
Document the evidence basis or rationale for chosen interventions when possible
Recognize that evidence strength varies across intervention types and intensities
Perform regular data analysis to inform modifications and demonstrate effectiveness
Supervision and coordinationCase supervision by BCBA®, LBA, or independently licensed clinician with ABA training; coordination with stakeholders and other providers is required.
Modality and flexibilityABA interventions range from structured, adult-directed methods to naturalistic, play-based approaches; modality selection (in-person, telehealth, hybrid) is individualized.
inv-44: Severe Behavior — definition for severe behavior
DefinitionSevere behavior: behaviors occurring at a rate, duration, intensity and/or episodic severity that interfere with autonomy and independence, pose risk of harm, and may include self-injury, aggression, property destruction, pica, elopement, and other high‑risk behaviors.
ConsequencesSuch behaviors are destructive/disruptive to daily life and may endanger the individual, others, or property and often require specialized, intensive treatment.
Program implicationPresence of severe behavior may necessitate focused intensive programs, higher staff-to-client ratios, and increased case supervision.
inv-45: Measurable Goals — definition and expectations
DefinitionMeasurable goals: operational, quantifiable descriptions of target behaviors that specify the method and units of measurement used to demonstrate progress toward mastery.
ComponentsEach goal must include a clear mastery criterion, consistent quantitative unit(s) of measurement (e.g., rate, percent per opportunity, duration), and dates for data collection.
Use in planningGoals must be developmentally appropriate, tied to ASD-related deficits, and inform progress monitoring, generalization, and discharge planning.
inv-46: Credentials — BACB credentialing levels and notes
BACB credential levelsBCBA®: graduate‑level professional who practices independently and provides supervision; BCaBA®: undergraduate‑level practitioner who works under BCBA supervision; RBT®: paraprofessional who practices under close, ongoing supervision.
Supervisory roleBCBA/ LBA or independently licensed clinician with ABA training must provide case supervision and document supervisor name and credentials.
DocumentationSupervisor credentials and the supervision plan/intensity should be recorded in clinical documentation and treatment plans.
inv-47: Severe Behavior — alternate/duplicate severe behavior definition
Definition (alternate)Severe behavior: behaviors with rate, duration, intensity or episodic severity that interfere with autonomy, pose risk of harm, and may require specialized, intensive treatment.
ExamplesMay include self‑injury, aggression, property destruction, pica, elopement, and other high‑risk behaviors requiring focused intervention.
Program requirementsRequests for Severe Behavior Programs require documentation of baseline data within 60 days, treatment history, safety protocols, and medical/mental health consultation.
inv-48: ABA — concise ABA definition (duplicate)
Concise definitionABA is the process of systematically applying interventions based on learning theory principles to improve socially significant behaviors and to demonstrate that interventions are responsible for observed changes.
Evidence baseABA methods are the basis for many evidence‑based treatment models for ASD and vary from structured to naturalistic approaches.
Outcome focusInterventions target skill acquisition and reduction of behaviors that interfere with progress, with efficacy demonstrated via data collection and analysis.
inv-49: Discharge / Transition — discharge and transition definition
Discharge definitionDischarge: the end of services between a provider and an individual; should comply with applicable state laws/regulations.
Transition definitionTransition: a coordinated, individualized, results‑oriented set of activities designed to move the individual through treatment toward discharge with monitoring and evaluation details.
Planning expectationsTransition and discharge planning should be collaborative, include fading strategies, and define measurable discharge criteria tied to DSM-5-TR‑defined ASD effects.
inv-50: Applied Behavior Analysis and related interventions — referenced literature and interventions list
Referenced literaturePolicy references multiple sources on behavioral interventions including EIBI/EIBI systematic reviews, TEACCH, DIR/Floortime, parent‑training programs, and severe behavior program toolkits.
Interventions listedIncludes early intensive behavioral interventions (EIBI), discrete trial training, pivotal response training, reciprocal imitation training, TEACCH, DIR/Floortime, and parent/caregiver training approaches.
Severe behavior resourcesCites resources and toolkits for developing Severe Behavior Programs and literature on managing challenging behaviors and restraint use.
Admission to Severe Behavior Program:
Complete treatment and behavior history, documentation of necessity (response to prior/current treatment), assessment within 60 days, baseline data demonstrating Severe Behavior, safety protocols, and documented medical/mental health consultation.
Continued Stay in Severe Behavior Program: Current quantitative data collected within 60 days, data meeting Severe Behavior definition, ongoing documented consultation and safety measures, and evidence of progress or protocol modifications with monitoring.
inv-53: Outpatient / Community / Residential (as applicable)
Admission: Individual requires ABA services in a given community/residential setting due to behaviors or skill deficits that cannot be addressed in a less intensive setting; documentation from assessments supports need.
Setting-specific admission depends on goals and environmental variables.
Continued Stay: Ongoing measurable progress toward goals or documented clinical need for continued intervention based on data; supervision and plan updates as needed.
Supervision intensity tied to direct treatment hours and individual needs.
Intensive needs admission: Individuals with severe behavior requiring focused treatment in more intensive settings (specialized intensive outpatient, day-treatment, residential) may require higher staff-to-individual ratios and greater supervision, especially during assessment and early treatment.
Intensity and staffing adjusted per individual needs.
Continued supervision and progress review: Ongoing supervision and regular data analyses are required to justify continued services and to intervene if expected progress is not observed.
Regular data collection by technicians and analysis by analysts is required.
inv-56: ABA service and stakeholder training
Service delivery and stakeholder training requirements
Stakeholder Training Requirements: Stakeholder training must be provided by BCBA, LBA, or independently licensed mental health professional with documented ABA training; include individualized measurable stakeholder goals with mastery criteria, quantitative baseline data with dates, documented data collection plan for progress, separate documentation when multiple stakeholders/settings involved, and trainer name/credentials.
Direct Service Delivery: When services occur in settings with other behavioral expectations, documentation must show treatment is direct engagement, indicates whether services aim to ameliorate ASD symptoms per DSM-5-TR, aligns with treatment plan goals, provider remains in line of sight and close proximity (except telehealth), data justify need for direct intervention for behaviors targeted for reduction, and services are not used to replicate responsibilities of the setting (e.g., classroom aide).
inv-57: ABA Program Criteria
Core ABA practice and program criteria
Core ABA: Objective assessment, environmental analysis, dignity promotion, application of behavior analysis principles, and ongoing objective data analysis to inform decisions.
From ABA core characteristics
Assessment Components: Assessment includes baseline skill determination, functional behavior assessment, skills-based and standardized assessments, risk assessment, and review of external professional assessments.
Used to develop treatment plan and measures to report progress
Treatment Plan Requirements: Treatment plan/plan of care must specify course of intervention, measurable goals, intensity (direct hours/week), staffing, settings, and monitoring/evaluation details including transition plan.
Plan should substantiate medical necessity criteria
inv-58: ABA service delivery and oversight
General service delivery and clinical practice expectations for ABA services.
Service delivery modalities: Services may be delivered in-person, via telehealth, or hybrid; modality selection is individualized based on patient, plan, caregiver, environment, efficacy, safety, and technology.
Supervision linked to direct treatment: Case supervision intensity should be determined by the number of direct treatment hours and individual needs (e.g., rapid progress, barriers, severe behaviors), with increased supervision for severe behavior and intensive settings.
Progress measurement: Behavior technicians collect data on treatment targets and behavior analysts analyze data regularly to monitor progress, assess program effectiveness, and guide intervention changes.
Modality (in-person, telehealth, hybrid) is permitted; selection must be individualized based on patient characteristics, treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technology considerations.
inv-62: Early intensive behavioral interventions (EIBI) / ABA-based programs
EIBI expectations: Early intensive behavioral interventions (EIBI) are ABA-based programs supported by limited RCTs and single-subject literature; program selection should consider available evidence and individual needs.
Evidence base limited; individualized selection recommended
inv-63: ABA and related behavioral interventions (EIBI, TEACCH, DIR/Floortime, parent training)
Referenced interventions: ABA and related behavioral interventions (EIBI, TEACCH, DIR/Floortime, parent training) are acknowledged; selection and use should be evidence-informed and individualized to the person's needs.
References cited
Intensity specificationTreatment intensity in the plan of care should state the number of direct ABA hours/week; supervision, caregiver training, and other services are not counted as direct hours.
Individual determinationNumber of hours is determined by multidimensional assessment and data on individual needs, response to treatment, and goals rather than preset visit caps.