ModifiedExcellus Health Plan IncPolicy 3.01.11

Applied Behavior Analysis

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Medical necessity review and coverage of Applied Behavior Analysis services for members with a DSM-5-TR diagnosis, including assessment, treatment, documentation, continued-therapy review, and provider requirements.

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ModifiedExcellus Health Plan IncPolicy 3.01.11

Applied Behavior Analysis

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Policy Summary

PayerExcellus Health Plan Inc

PolicyApplied Behavior Analysis

Policy CodePolicy 3.01.11

Change TypeModified

Effective DateJune 18, 2026

Next Review DateJune 1, 2027

Key ActionFor continued ABA therapy, submit services received, measurable progress, and clinical support that stopping treatment would likely cause decompensation, loss of progress, or recurrence of symptoms.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review states that the policy intent was unchanged.

On September 2, 2025, HCPCS codes that were not ABA codes were removed from the policy.

12 monthsTreatment-plan documentation

MonthlyMinimum documentation update

5 domainsMeasurable progress domains

20-40 hours/weekEarly intensive ABA intensity

Ages 3-21School-program exclusion age range

Coverage Criteria

Medically Appropriate ABA Assessment and Treatment

Applied Behavior Analysis (ABA) is considered medically appropriate when used in the assessment and treatment of the member's DSM-5-TR diagnosis.

ALL of the following

The member has a diagnosis meeting DSM-5-TR criteria.
The assessment and treatment may include a complete medical and developmental history.
The assessment and treatment may include a psychological and/or psychiatric evaluation.

Treatment Plan Requirements

ABA services must be supported by a documented treatment plan.

ALL of the following

The treatment plan clearly defines treatment goals and objectives.
The treatment plan includes discharge criteria.
The treatment plan and goal progress notes are submitted for review at least once every 12 months or as state mandated.
Documentation demonstrates monthly updates, at a minimum.
The treatment plan may be requested at any point during treatment for continuity-of-care review or periodic concurrent medical-necessity review.

Continuation Therapy Documentation

Requests for continued therapy must include documentation of services received and a graphic representation of the member's measurable progress.

ALL of the following

There is a reasonable expectation that the member will benefit from continuation of ABA therapy, evidenced by measurable progress toward or mastery of treatment goals or modification of the treatment plan in response to prior interventions.
Treatment is not making the member's symptoms worse.
Continued progress is documented through improvement in goals outlined in the provider treatment plan across applicable domains, including communication, social functioning, adaptive behavior, daily living skills, and reduction of interfering behaviors.

Continued Therapy: Clinical Risk and Measurable Progress

Continued ABA therapy is supported when the clinical record demonstrates ongoing benefit and risk from withdrawal.

ALL of the following

There is a reasonable expectation, based on the member's clinical history, that withdrawal of treatment will result in decompensation, loss of progress made, or recurrence of signs and symptoms.
The member demonstrates measurable progress toward or mastery of treatment goals, or the treatment plan has been modified in response to prior interventions.

Provider Qualification and Supervision

Eligible ABA services must be delivered by, or under the clinical direction and supervision of, a qualified behavior analyst.

ALL of the following

A qualified behavior analyst, such as a Licensed Behavior Analyst (LBA) or Board-Certified Behavior Analyst (BCBA), is responsible for assessment, treatment planning, and oversight of care.
Assistant-level behavior analysts, such as a Certified Behavior Analyst Assistant (CBAA) or Board-Certified Assistant Behavior Analyst (BCaBA), provide services under the direction and supervision of a qualified behavior analyst.
Trained paraprofessionals, such as behavior technicians or Registered Behavior Technicians (RBTs), provide direct, protocol-driven services under direction and supervision of a qualified behavior analyst.
Paraprofessionals and assistant-level personnel implement treatment plans and collect data but do not perform activities requiring independent clinical judgment, including assessment, diagnosis, or modification of treatment plans.
An LBA or equivalent qualified behavior analyst must meet ALL of the following

Caregiver and School Coordination

Parent/caregiver participation and coordination with the school district are required components of the ABA program.

ALL of the following

The parent or caregiver participates in the ABA program.
When applicable, an IEP is completed through the school district before a request for coverage is submitted to the Health Plan.
For a home-schooled child, an assessment by the school district is completed before submitting a coverage request.
Requests for home-schooled children outside New York State are reviewed individually in accordance with the regulations of the state in which the member resides.

ABA Services for Autism Spectrum Disorder

In New York State, ABA is included as behavioral health treatment for an individual diagnosed with autism spectrum disorder (ASD) when the applicable coverage conditions are met.

ALL of the following

The service is screening, diagnosis, or treatment of autism spectrum disorder.
ABA is provided by a person licensed, certified, or otherwise authorized to provide ABA.
The service is necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of the individual.
Coverage is subject to applicable annual deductibles, copayments, coinsurance, utilization review, and external appeal rights.

Supplemental ABA Services

Coverage may be available for ABA services provided on a supplemental basis outside the educational setting.

ALL of the following

The services are provided outside the educational setting on a supplemental basis.
The services are prescribed by a licensed physician or licensed psychologist.
The services are not covered by the member's IEP.

Coverage is not available for services stipulated in the IEP of a preschool member ages three to five years or a school-age member ages five to 21 years. These services are provided by the member's school district and are considered free care or a government program.

Parent support groups are not considered medically necessary. Parent and caregiver participation in the ABA program remains a required component of covered ABA treatment.

IEP-stipulated services for preschool members ages three to five years and school-age members ages five to 21 years are excluded from coverage because they are the responsibility of the member's school district.

Parent support groups are not considered medically necessary and are not covered as medically necessary ABA treatment.

School districts are responsible for services provided under an Individualized Education Program (IEP), an Individualized Family Service Plan (IFSP), or an Individualized Services Plan (ISP), in accordance with applicable federal and New York State law.

Services are contract dependent. If a product does not cover a service, medical policy criteria do not apply.

If a commercial product, including an Essential Plan or Child Health Plus product, covers a specific service, medical policy criteria apply to the benefit.

If a Medicaid product covers a specific service and there are no New York State Medicaid guidelines (eMedNY) criteria, medical policy criteria apply to the benefit.

If a Medicare product, including a Medicare HMO-Dual Special Needs Program (DSNP) product, covers a specific service and there is no national or local Medicare coverage decision, medical policy criteria apply to the benefit.

If a Medicare HMO-Dual Special Needs Program (DSNP) product does not cover a specific service, refer to the Medicaid product coverage line.

Parent or caregiver participation is required as part of the ABA program. Parent support groups are not considered medically necessary.

Coverage does not include parent support groups because they are not considered medically necessary services.

Coding and Service Parameters

CPT CodesCPT

97152	Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.
0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by the physician or other qualified health care professional who is on site, assistance of two or more technicians, a patient who exhibits destructive behavior, and completion in an environment customized to the patient's behavior.
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring administration by the physician or other qualified health care professional who is on site, assistance of two or more technicians, a patient who exhibits destructive behavior, and completion in an environment customized to the patient's behavior.

HCPCS CodesHCPCS

No codes listed

ICD-10 CodesICD-10

No codes listed

HCPCS CodesHCPCS

Not Applicable

ICD10 CodesICD-10

Multiple Codes

Early Intensive Behavioral Intervention Intensity

Typical intensity20-40 hours per week

Treatment basisEarly intensive behavioral intervention is grounded in the principles of Applied Behavior Analysis.

Intensity planningTreatment intensity should be individualized based on clinical need.

Early Intensive Behavioral Intervention Duration

Typical duration1-4 years

Intervention type

Provider Requirements and Submission Guidance

Documentation Required

Provider Requirements and Medical-Necessity Review

Providers must meet the Health Plan’s requirements for referral and provision of ABA services. Submit the required clinical documentation for medical-necessity review when applicable.

Ensure the referral, treating professional, requested services, and supporting records satisfy applicable medical-necessity review requirements.

Prior Authorization

Prior Authorization for Continued Therapy

Prior authorization is required for continued ABA therapy. Requests must document services received and clinical evidence supporting continued medical necessity and benefit.

Include progress documentation, treatment-plan updates, and the clinical rationale for continuation.
Submit records at the intervals required by the Health Plan or applicable state requirements.

Policy Background

Applied Behavior Analysis (ABA) is considered medically appropriate for the assessment and treatment of a member's DSM-5-TR diagnosis. The policy permits medical, developmental, psychological, and psychiatric evaluation as part of assessment and treatment, with goals that may address communication, social functioning, adaptive behavior, daily living skills, and reduction of interfering behaviors.

Definitions

Applied Behavior Analysis (ABA)

DefinitionAn evidence-based treatment approach grounded in principles of behavior analysis.

Measurement approachUses objective measurements and data to increase adaptive behaviors.

Treatment focusReduces behaviors that interfere with learning and functioning.

Delivery rangeABA interventions range from structured, adult-directed approaches to naturalistic interventions using play, daily routines, and natural environments.

Early Intensive Behavioral Intervention (EIBI)

DefinitionEarly intensive behavioral intervention grounded in the principles of Applied Behavior Analysis.

Applied Behavior Analysis Criteria

ABA Medical Appropriateness

ABA is considered medically appropriate for assessment and treatment of the member’s DSM-5-TR diagnosis.

ABA assessment and treatment services: The member has a DSM-5-TR diagnosis and the requested service is part of assessment or treatment for that diagnosis.

Services may include a complete medical and developmental history and psychological and/or psychiatric evaluation.

Continuation Criteria

Continuation requests must demonstrate ongoing benefit and medical necessity.

Continued ABA: The member is making measurable progress or the treatment plan has been appropriately modified; treatment is not worsening symptoms; and withdrawal is reasonably expected to cause decompensation, loss of progress, or recurrence of signs and symptoms.Measurable progress or treatment-plan modification

Progress may be demonstrated in communication, social functioning, adaptive behavior, daily living skills, and reduction of interfering behaviors.

Treatment Modalities

Applied Behavior Analysis

ABA may be delivered through the following treatment modality when clinically appropriate.

ABA delivery: ABA may be delivered in person or through telehealth when clinically appropriate, with ongoing case supervision by a qualified behavior analyst throughout treatment.

Supervision is generally proportional to treatment dosage; supervision ratios may vary according to client complexity, treatment phase, and payer requirements. Telehealth limitations include individual characteristics, caregiver availability, and treatment-environment features.

Policy Summary

PayerExcellus Health Plan Inc

PolicyApplied Behavior Analysis

Policy CodePolicy 3.01.11

Change TypeModified

Effective DateJune 18, 2026

Next Review DateJune 1, 2027

SourceLink

On This Page

Hold a master's or higher degree from a program registered by the New York State Education Department or determined by the Department to be substantially equivalent.
Have experience in the practice of ABA satisfactory to the New York State Board of Applied Behavioral Analysis and the Department, in accordance with the commissioner's regulations.
Pass an examination acceptable to the Board and the Department, in accordance with the commissioner's regulations.
Be at least 21 years of age.
Be of good moral character, as determined by the Department.

A CBAA must meet ALL of the following

Hold a bachelor's degree or higher degree from a program registered by the New York State Education Department or determined by the Department to be substantially equivalent.
Have experience in the practice of ABA satisfactory to the New York State Board of Applied Behavioral Analysis and the Department, in accordance with the commissioner's regulations.
Pass an examination acceptable to the Board and the Department, in accordance with the commissioner's regulations.

Early intensive behavioral intervention is a long-term treatment approach for young children with autism spectrum disorder.

Evidence contextEIBI is among the most well-established treatment approaches for young children with autism spectrum disorder.

Listed ABA Service Time Unit

Listed service time unitEach 15 minutes

Assessment servicesBehavior identification-supporting assessment services are reported in 15-minute units.

Treatment servicesAdaptive behavior treatment services with protocol modification are reported in 15-minute units.

Documentation Required

School Assessment Before Submission

Before submitting a coverage request, obtain the applicable school-district assessment. For a home-schooled child, the school-district assessment should be completed before the request is submitted.

Requests for home-schooled children outside New York State are reviewed individually under the regulations of the state of residence.

Documentation Required

Testing and Educational-Program Records

Submit testing and educational-program records relevant to the medical-necessity determination.

Documented psychological and/or other completed testing.
The member’s IEP, when applicable.
Progress notes and the discharge plan from an Early Intervention or Pre-School Special Education Program, when applicable.

Documentation Required

Service and Provider Details

Include the requested ABA service parameters and the qualifications of the professional providing ABA.

Frequency, duration, and location of requested ABA sessions.
Certification and credentials of the ABA professional.

Documentation Required

Treatment Plan and Supervision Documentation

ABA services must have a documented treatment plan with clearly defined goals, objectives, and discharge criteria. Submit the plan and goal-progress notes for review at least every 12 months or as state mandated; documentation should demonstrate monthly updates at a minimum.

The treatment plan may be requested at any point for continuity-of-care or periodic concurrent medical-necessity review.
Include the requested clinical-supervision hours and supporting documentation.
Include an assessment or treatment plan identifying the target behaviors for ABA.

Documentation Required

Continued-Therapy Progress Documentation

Requests for continued therapy must include documentation of services received and a graphic representation of measurable progress. The record must support continued benefit, absence of worsening, and clinically meaningful progress across applicable treatment-plan domains.

Show measurable progress toward or mastery of goals, or modification of the treatment plan in response to prior interventions.
Document progress in applicable domains, including communication, social functioning, adaptive behavior, daily living skills, and reduction of interfering behaviors.
Document that treatment is not making symptoms worse.

Prior Authorization

Complete Applicable IEP Before Request

When applicable, the member’s IEP must be completed through the school district before a request for coverage is submitted to the Health Plan.

Obtain and submit the completed IEP with the coverage request when applicable.

Documentation Required

Document Measurable Progress

Continued therapy must be supported by documented, measurable improvement in the goals identified in the provider’s treatment plan.

Use progress data or graphic documentation to demonstrate ongoing benefit and improvement across applicable domains.

Denial Risk

Medical-Necessity Rationale

The continuation request must explain why stopping treatment is clinically unsafe or inappropriate, based on the member’s clinical history.

Document the reasonable expectation that withdrawal would cause decompensation, loss of progress, or recurrence of signs and symptoms.

Documentation Required

IEP or School-District Assessment

Obtain the applicable IEP or school-district assessment before submitting the request. A home-schooled child requires a school-district assessment before submission.

Apply the individual review process for home-schooled children outside New York State under the laws and regulations of the state where the member resides.

Denial Risk

Non-ABA Methods Are Investigational

Non-ABA intervention methods are considered investigational, including DIR/Floortime, TEACCH, RDI, and other similar non-ABA methods.

Do not represent non-ABA methods as covered ABA services.

Billing Rule

IEP or School-District Services Excluded

Coverage is not available for services stipulated in the IEP of a preschool member ages 3–5 or a school-age member ages 5–21 because those services are provided by the school district as free care or a government program.

Identify and exclude services that are the school district’s responsibility under the applicable educational program.

Unsupported block type: documentation

Denial Risk

Insufficient Continued-Treatment Justification

A continued-treatment request may be denied when it does not demonstrate ongoing benefit or the consequences of withdrawing treatment.

Show measurable progress toward or mastery of goals, or explain treatment-plan modification in response to prior interventions.
Explain the expected decompensation, loss of progress, or recurrence of symptoms if treatment is withdrawn.
Document that treatment is not worsening symptoms.

Billing Rule

School-Provided Services and Parent Support Groups

School-provided services and parent support groups are not covered as medically necessary ABA services. Services in an applicable IEP are the school district’s responsibility; parent support groups are specifically not medically necessary.

Review the IEP and educational program to separate school-provided services from supplemental services requested from the Health Plan.
Do not submit parent support groups as medically necessary ABA treatment.

Prior Authorization

School-District Coordination

ABA services denied by the school district, including summer services, or not covered in the child’s IEP may be reviewed by the Health Plan for medical necessity under the member’s subscriber contract.

Coordinate with the school district and document services denied by the district or absent from the IEP.
Interim summer programs may be provided by school districts when a child requires a structured 12-month learning environment to maintain developmental levels or prevent substantial regression.

Billing Rule

Educational-Program Responsibility

School districts are responsible for services provided under an IEP, IFSP, or ISP under applicable federal and New York State law. Health Plan coverage may be available for supplemental services outside the educational setting when prescribed by a licensed physician or psychologist and not covered by the IEP.

Verify whether the requested service belongs under an IEP, IFSP, or ISP before seeking Health Plan coverage.
Document that supplemental services are outside the educational setting and are not covered by the applicable educational plan.

20-40 hours per week.

Typical duration1-4 years.

Clinical planningTreatment intensity should be individualized based on clinical need.

Naturalistic Developmental Behavioral Interventions (NDBIs)

DefinitionInterventions that integrate applied behavioral and developmental approaches.

Teaching approachUse behavioral teaching strategies to promote developmentally appropriate skills within natural environments, such as play and routine activities.

Interaction modelTypically incorporate child-initiated interactions and naturally occurring reinforcement.

Developmental focusEmphasize social communication, engagement, and skill acquisition within typical developmental processes.

E/I

AbbreviationE/I

MeaningExperimental/Investigational

Policy useCodes marked E/I indicate experimental/investigational services.

NMN

AbbreviationNMN

MeaningNot medically necessary/appropriate

Policy useCodes marked NMN indicate services that are not medically necessary or appropriate.

Applied Behavior Analysis Program Criteria

ABA coverage and continued therapy require clinical oversight, caregiver participation, and documentation of measurable progress.

ABA program requirements

Qualified clinical oversight: A qualified behavior analyst is responsible for assessment, treatment planning, and oversight of care; assistants and paraprofessionals work within supervised roles.
Caregiver participation: Parent or caregiver support and participation are required components of the ABA program.
Progress documentation: Continued-therapy requests include documentation of services received and a graphic representation of measurable member progress against treatment-plan goals.

ABA Coverage Criteria

ABA is covered for ASD when the following conditions are met.

ABA clinical and provider criteria: The patient has autism spectrum disorder; the ABA provider is licensed, certified, or otherwise authorized to provide ABA; treatment is necessary to develop, maintain, or restore, to the maximum extent practicable, functioning; and supplemental services outside the educational setting are prescribed by a licensed physician or licensed psychologist when not covered by an IEP.

New York State Insurance Law does not specify an age limitation for ABA services.