Applied Behavioral Analysis (ABA) therapy coverage — Clinical/Medical Policy (Coverage Criteria)
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Defines medical necessity, prior authorization, coding, and limits for Applied Behavioral Analysis (ABA) services for applicable Harvard Pilgrim and Tufts commercial products and Tufts Health Direct; includes coverage for ASD and, in Massachusetts products, Down syndrome when criteria are met.
Coverage for ABA for Down Syndrome was added for Massachusetts products per state law.
InterQual criteria modification: age-related 'Limited Evidence' will not be used for ABA requests ages 13-20; standard InterQual criteria apply.
H0031 and H0032 were removed from the list of applicable codes for HPHC Commercial.
Coverage and Medical Necessity Criteria
Coverage criteria (Initial and ongoing ABA services)
Covered when ALL of the following are met:
See applies to and product lists.
Down syndrome coverage is Massachusetts-specific per state modification.
InterQual tools drive authorization decisions and may be customized by payer.
Use Massachusetts Standard Form for Massachusetts Commercial and Direct Plans; use Autism Spectrum Disorder Services Prior Authorization Request Form for all other states. Electronic submission via HPHConnect is recommended.
The policy excludes services that are primarily educational in nature, services provided by school personnel under an Individualized Education Program (IEP), and treatments considered investigational or unproven. Examples of excluded investigational therapies include facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, and Higashi (Daily Life Therapy). Personal training or life coaching is also excluded.
Applied Behavioral Analysis (ABA) therapy is considered not medically necessary when the services requested are primarily educational, when the services are provided by school personnel pursuant to an Individual Education Program (and therefore not subject to reimbursement), or when the treatment is investigational or unproven. Specific investigational examples listed in the policy include facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, and Higashi (Daily Life Therapy). The policy also lists personal training or life coaching as non-covered.
Diagnosis and Procedure Codes
| F84.0 | Autistic disorder |
| F84.3 | Other childhood disintegrative disorder |
| F84.5 | Asperger's syndrome |
| F84.8 | Other pervasive developmental disorders |
| F84.9 | Pervasive developmental disorder, unspecified |
| Q90.0 | Trisomy 21, nonmosaicism (meiotic nondisjunction) |
| Q90.1 | Trisomy 21, mosaicism (mitotic nondisjunction) |
| Q90.2 | Trisomy 21, translocation |
| Q90.9 | Down syndrome, unspecified |
| 97151 | Behavior identification assessment, each 15 minutes, includes face-to-face with patient and/or guardian(s)/caregiver(s) and non-face-to-face work |
| 97152 | Behavior identification-supporting assessment, technician, face-to-face, each 15 minutes |
| 97153 | Adaptive behavior treatment by protocol, technician, face-to-face with one patient, each 15 minutes |
| 97154 | Group adaptive behavior treatment by protocol, technician, face-to-face with two or more patients, each 15 minutes |
| 97155 | Adaptive behavior treatment with protocol modification, clinician, may include direction of technician, each 15 minutes |
| 97156 | Family adaptive behavior treatment guidance, clinician, face-to-face with guardian(s)/caregiver(s), each 15 minutes |
| 97157 | Multiple-family group adaptive behavior treatment guidance, clinician, face-to-face with multiple sets of guardians/caregivers, each 15 minutes |
| 97158 | Group adaptive behavior treatment with protocol modification, clinician, 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, with physician on site and 2+ technicians, for destructive behavior |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face requiring physician on site and 2+ technicians for patients with destructive behavior |
Prior Authorization, Documentation, and Denials
Prior authorization required for specified ABA codes
Prior authorization is required for the listed ABA CPT/HCPCS codes and must be obtained through the payer's prior authorization process using the required InterQual subsets/SmartSheets and submission channels (HPHConnect).
Follow InterQual/HPHConnect workflow; note age-related criterion modification
Providers must follow the InterQual-based authorization workflow and use HPHConnect to request authorization; the policy alerts providers that InterQual tools may be customized by the payer and that age-related InterQual 'Limited Evidence' will not automatically trigger review for ages 13–20.
- Request authorization and complete the automated authorization questionnaire via HPHConnect.
- Be aware InterQual criteria may be customized by Harvard Pilgrim; for ages 13–20 the payer will not use the InterQual age-related 'Limited Evidence' flag as an automatic trigger for secondary review.
Required clinical documentation submission methods
When clinical documentation is required for the prior authorization review, submit clinical notes or written documentation electronically via HPHConnect Clinical Upload or by secure fax to 800-232-0816.
- HPHConnect Clinical Upload is the recommended submission method.
- If faxing, use secure fax number: 800-232-0816.
Denial risks — services considered not medically necessary
Services meeting any of the policy's exclusion criteria are considered not medically necessary and may be denied; providers should avoid billing for these services as ABA covered care.
- Denial triggers include services that are primarily educational in nature.
- Services provided by school personnel pursuant to an Individual Education Program are not subject to reimbursement.
- Investigational or unproven treatments (e.g., facilitated communication, Auditory Integration Therapy, Holding Therapy, Higashi) and personal training/life coaching are considered not medically necessary.
Background and Rationale
Applied Behavioral Analysis (ABA) is a behavioral treatment approach used to address socially significant behaviors through assessment, structured intervention, and measurement of outcomes. While this policy focuses on coverage criteria, prior authorization, and use of InterQual tools to determine medical necessity, it notes that ABA services provided in educational settings by school personnel are excluded from coverage and that investigational modalities (for example, facilitated communication or Auditory Integration Therapy) are not considered medically necessary.
Key Definitions
Service Setting and Level-of-Care
Outpatient / Home-based ABA services
Use the appropriate state-specific prior authorization form.
Parent/guardian involvement is required and must be documented.
Document rationale for discharge in clinical record.
InterQual-based ABA Clinical Criteria
InterQual-based ABA criteria
InterQual subsets/Smartsheets required for prior authorization and evaluation of medical necessity
These InterQual tools drive authorization decisions; Down Syndrome has been added as a qualifying diagnosis in applicable states and age-related 'Limited Evidence' for ages 13-20 will not automatically trigger secondary review.
Covered Treatment Modalities and Supervision
ABA (assessment, individual treatment, group treatment, parent guidance, supervision)
Codes specify modality details and who may deliver the service; parent/legal guardian involvement is considered essential to long-term treatment success.
Visit Frequency, Duration, and Limits
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