CurrentKaiser PermanentePolicy N/A

Applied Behavior Analysis (ABA) services for Autism Spectrum Disorder

Medical necessity criteria and utilization management guidelines for authorization, continuation, and documentation of ABA services for members with Autism Spectrum Disorder (ASD) under Kaiser Permanente Georgia Region.

Policy Summary

PayerKaiser Permanente

PolicyApplied Behavior Analysis (ABA) services for Autism Spectrum Disorder

Policy CodePolicy N/A

Change TypeReviewed/Revised

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization with documentation of a diagnostic evaluation within 3 years, individualized treatment plan with measurable six-month goals, and required caregiver training goals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 codesCovered CPT/HCPCS codes

max 2097151 unit limit

<21Member age limit

50%Improvement threshold

80%Caregiver participation

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Coverage and Medical Necessity Criteria

Initial Therapy

KPGA may authorize ABA services for ASD only when ALL of the following are met:

Initial Authorization Requirements: Comprehensive diagnostic evaluation (neurodevelopmental evaluation with detailed developmental history and developmental/cognitive scores) resulting in ASD diagnosis completed or updated within the past 3 years, with a recommendation for ABA treatment; Member is under age 21 years; Initial assessments and individualized treatment plan submitted that identify core ASD deficits, measurable goals, baseline/present levels, mastery criteria, and use of developmentally appropriate assessments (direct observation and curriculum-referenced assessments as applicable).

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Assessment

ABA assessment authorization criteria:

Assessment Limits: Numbers 1-3 of initial authorization criteria must be met; hours requested for assessment must not exceed what is required (CPT 97151 maximum 20 units/5 hours); additional clinical rationale required when combined assessment codes (97151 and 97152) exceed 5 hours (20 units).97151 <= 20 units

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Initial and Ongoing Treatment

Initiation or ongoing ABA services may be authorized when ALL of the following are met:

Diagnostic and Non-duplication: Diagnostic criteria per the current DSM are met; ABA services do not duplicate educational supports (IEP/ISP) or services provided by other medical or behavioral health professionals (e.g., individual/group/family therapy, OT, PT, speech); ABA is not a substitute for non-treatment environmental supports (shadow, paraprofessional, companion services).

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Treatment Plan Requirements: An individualized treatment plan is submitted by a BCBA/LBA including measurable six-month goals, baseline/present levels, objective mastery criteria with estimated date of mastery, a plan for generalization across stimuli/contexts/people, and functional behavior assessment with operational definitions for targeted behaviors; documentation of participants, procedures, setting, and coordination with other treating providers is required.Goals reasonably achievable within 6 months

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Provider and Delivery: Services are provided by appropriately credentialed personnel (RBT/BCaBA/BCBA/LBA/LABA) with BCBA supervision consistent with controlling state mandates; telehealth is not approved for direct ABA delivery except as allowed by the member benefit plan for parent education/supervision and should be combined with face-to-face supervision when used.

Continuation Therapy

Continued authorization may be granted only when ALL of the following are met:

Demonstrated Improvement: Current ABA treatment demonstrates significant improvement defined as mastery of at least 50% of stated goals and measurable functional improvement on adaptive/cognitive/language testing; there is a reasonable expectation that proposed goals will be mastered within the requested six-month authorization period and will assist independence/functional improvement.>=50% goals mastered

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Documentation for Continued Care: Submit updated adaptive behavior testing (e.g., Vineland) as required (annually within 45 days of next scheduled concurrent review) and a complete medical record by the BCBA/LBA including collected data (progress graphs, ABLLS/VBMAPP or other non-standardized assessments) linking interventions to specific goals; updated treatment plan with measurable six-month goals and evidence of generalization and caregiver training progress.Vineland annually

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Caregiver Training and Authorization

Covered when ALL of the following are met

Caregiver training requirements: Caregiver participation is expected for at least 80% of agreed-upon caregiver training sessions; caregiver training goals for each authorization period must be specific, include mastery criteria, data collection, behavior management procedures, and a plan for generalization; recommended dosing is one hour of caregiver training for the first 10 hours of direct line therapy and an additional 0.5 hours for every subsequent 10 hours of direct therapy unless contraindicated or caregiver declines; if caregivers decline participation, include a generalization plan and a plan to increase participation.80% participation; 1 hr per 10 hrs then 0.5 hr per 10 hrs

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Ordering and Referral

Covered when ALL of the following are met

Ordering provider: ABA may be ordered only by Developmental Pediatrics clinicians; requests from other providers (e.g., pediatricians) will be routed to the QRM MD for soft denial and Developmental Pediatrics will coordinate evaluation and next steps.

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Treatments other than Applied Behavior Analysis (ABA) are outside the scope of this policy and are considered investigational/experimental. Examples include, but are not limited to, Cognitive Training; Auditory Integration Therapy; Facilitated Communication; Higashi Schools/Daily Life, Individual Support Program; LEAP; SPELL; Waldon; Hanen; Early Bird; Bright Start; Social Stories; Gentle Teaching; Response Teaching Curriculum and Developmental Intervention Mode; Holding Therapy; Movement Therapy; Music Therapy; Pet Therapy; Psychoanalysis; Son-Rise Program; Scotopic Sensitivity Training; Sensory Integration Training; and Neurotherapy (EEG biofeedback).

Caregiver training as covered by this policy is education and development of caregiver‑mediated ABA strategies and related procedures directed at facilitating skill acquisition, generalization, and treatment integrity. Caregiver training does not include training of teachers, other school staff, other health professionals, or other counselors or trainers. The policy does permit caregiver training to include instruction to caregivers on how to train other professionals or people involved in the member’s life.

ABA services will not be authorized when they duplicate supports or services provided through educational plans (for example, IEP/ISP) or when they mirror other medical or behavioral therapies. Providers must document why ABA is distinct and medically necessary relative to educational academic supports or concurrent therapies, and the treatment plan should explain coordination with other treating providers to avoid duplication of services.

Requests that do not meet the QRM medical necessity criteria will not be approved. Common examples include: requests for services beyond the covered age limit — services are not covered beyond age 20 — and requests that fail to meet documented assessment or treatment criteria. Additionally, requests from non‑contracted providers may be denied. Assessment requests that exceed standard limits (for example, >5 hours / >20 units for CPT 97151) require additional clinical rationale and may not be approved without that justification.

Billing Codes and Unit Limits

Covered CPT CodesCPTCovered

97151	Behavior Identification Assessment / ABA assessment (per policy: initial/re-evaluation; max 20 units)
97152	Adaptive behavior treatment by protocol (administration)
97153	Adaptive behavior treatment by protocol (direct one-on-one therapy)
97155	Adaptive behavior treatment with protocol modification (supervisory/consultative services; max 20% of total treatment hours approved)
97156	Family adaptive behavior treatment guidance (typical authorization 1-2 hours per week; 104-208 units per 6-month authorization)

Initial assessment unit limit — 97151

CodeCPT 97151

LimitMaximum 20 units (equivalent to 5 hours) for initial or re-evaluation assessments

Exceeding limitRequests for >20 units ( >5 hours) require additional clinical rationale

97155 proportion limit

CodeCPT 97155

Proportion limitMaximum 97155 ≤ 20% of total treatment hours approved

Concurrent billingConcurrent billing with 97153 and 97155 will not be approved

Provider Requirements, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for ABA services. A diagnostic neurodevelopmental evaluation (completed or updated within the past 3 years) supporting an ASD diagnosis and recommendation for ABA treatment is required for authorization. Members must meet age and other eligibility criteria in the policy.

Authorization requests must include the comprehensive diagnostic evaluation dated within 3 years and a recommendation for ABA (see Coverage Guidelines: Initial Service Request).
Assessment and treatment hour limits (see ABA Assessment and Hours to be Authorized) apply; requests exceeding standard limits require additional clinical rationale.
Authorized hours will be determined by TSPMG Developmental Pediatrics review of submitted ABA evaluation and treatment plan.

Documentation Required

Caregiver Training Documentation and Requirements

Caregiver training goals and documentation are required for each authorization period. Caregiver participation is expected and should be documented; if caregivers decline participation, include a structured generalization plan and steps to increase participation.

Clinical Background

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction across multiple contexts and by restricted, repetitive patterns of behavior, interests, or activities as described in DSM‑5. ABA is the evidence‑based behavioral treatment approach commonly used for children with ASD; it is characterized by applied, behavioral, analytic, technological, conceptually systematic and effective methods, typically delivered in structured environments with individualized treatment plans, predictable routines, transition and aftercare planning, and significant family involvement to increase adaptive skills and reduce problematic behaviors.

Definitions and Key Terms

Caregiver Training definition

DefinitionCaregiver Training: education and development of caregiver‑mediated ABA strategies, protocols, or techniques directed at facilitating, improving, or generalizing social interaction, skill acquisition, and behavior management; includes observational measures for treatment integrity.

Participation expectationCaregiver participation is expected for at least 80% of agreed upon caregiver training sessions scheduled between provider and caregiver

DocumentationCaregiver training goals must include mastery criteria, data collection, behavior management procedures, and a generalization plan for each authorization period

Core Deficits of Autism definition

Core areasPersistent deficits in social communication and social interaction across multiple contexts

Restricted behaviors

Level of Care Definitions

Comprehensive; Focused; Individualized

Treatment level classifications and typical intensity ranges:

Comprehensive Treatment: Comprehensive treatment targets deficits across all core ASD symptoms and includes direct 1:1 ABA, caregiver training, BCBA supervision and treatment planning; primarily directed to children ~18 months to 8 years and individualized to reduce the gap between chronological and developmental age.

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Focused Treatment: Focused treatment targets a limited number of behavior goals and typically ranges from 10 to 35 total hours of direct services per week; may include caregiver training as the only component and is individualized based on severity and needs.10-35 hours/week

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Individualized Consideration: Requested treatment hours outside the described ranges for comprehensive or focused treatment require specific clinical rationale and individualized review for medical necessity.

ABA Treatment Criteria and Assessments

ABA level definitions

Treatment classification and targeting definitions used to plan ABA services:

Treatment classification and targeting: Comprehensive ABA addresses deficits across all core symptoms and is often early intensive behavioral intervention; focused ABA targets specific behaviors or skill deficits with prioritized goals and may emphasize group work and parent training to enhance participation and adaptive skills; intensity and hours authorized are based on severity, prior response, and individual needs.

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Assessment tools for ABA

Definitions and assessment tools to support ABA service planning:

Acceptable assessment tools: Acceptable instruments include diagnostic instruments (e.g., ADOS-2, ADI-R, SRS-2, CARS-2), standardized cognitive assessments (e.g., WISC, Leiter, Bayley), curricular/non-standardized tools (e.g., ABLLS-R, VBMAPP, AFLS, Vineland) and stimulus preference or curriculum-referenced assessments to quantify baseline and measure outcomes; screening measures alone are insufficient for diagnosis and should be followed by comprehensive assessment.

Service Types and Modalities

ABA (direct therapy, supervision, family guidance)

Treatment modalities and delivery expectations:

Direct therapy, supervision, family guidance: Direct line therapy is provided by line therapists (RBT) or BCaBA/LABA under BCBA/LBA or BCBA-D supervision; 97156 is used for family adaptive behavior treatment guidance (typically 1-2 hours per week); concurrent billing of 97153 and 97155 will not be approved; 97155 limited to a maximum of 20% of total treatment hours approved.97155 <= 20% of total hours; 97156 1-2 hrs/week

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Telehealth and supervision: Telehealth/telemedicine is not an approved method for direct ABA services except as allowed by the member benefit plan for parent education and direct supervision activities and is recommended to be combined with face-to-face supervision when used.

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Caregiver training

Caregiver training modality and operational expectations:

Visit and Unit Limits

ABA assessment (97151)

CodeCPT 97151

LimitMax 20 units (5 hours) for initial or re-evaluation assessments

NotesAssessment hours generally max 5 hours without additional clinical rationale; requests >5 hours require additional rationale

Policy Revision History

2022-07-01policy_effective

Policy became effective for Kaiser Permanente Georgia region.

2024-08-08last_revisionLatest

Policy reviewed/revised as documented in header with last revision date recorded.

Policy Summary

PayerKaiser Permanente

PolicyApplied Behavior Analysis (ABA) services for Autism Spectrum Disorder

Policy CodePolicy N/A

Change TypeReviewed/Revised

Effective DateJul 1, 2022

Next Review DateN/A

SourceLink

On This Page

Intensity and Hours: Requested intensity and hours per week must not exceed the member's functional ability to participate or be for convenience; hours must be the minimum required to achieve treatment plan goals and reflect availability of the member, caregiver, and provider; focused and comprehensive treatment descriptions (and typical ranges) guide authorization and requests outside those ranges require specific clinical rationale.

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Reduction or Denial Conditions:

If the member fails to demonstrate measurable progress across successive authorizations or does not generalize skills despite caregiver training, coverage may be reduced or denied; treatment plans should address barriers to success when <50% mastery is achieved.

97156 authorization range

CodeCPT 97156

Weekly rangeTypical authorization 1–2 hours per week

Authorization units (6 months)104–208 units per 6-month authorization

PurposeUsed for family adaptive behavior treatment guidance (caregiver/family guidance)

Caregiver training goals must be specific to the member, include mastery criteria, date of introduction, current performance level, data collection methods, and a plan for generalization.
Recommended caregiver training dosing: 1 hour per first 10 hours of direct therapy, plus 0.5 hours per additional 10 hours, unless contraindicated or caregiver declines.
If caregiver participation <80% of agreed sessions, include a plan to increase participation and an alternative generalization plan in the request.

Note

Duplication Avoidance

Avoid duplication of services. ABA services must not duplicate educational or other therapeutic services (IEP/ISP, OT, PT, speech, psychological testing) and only portions of assessments addressing core ASD deficits are reimbursable.

Do not request ABA authorization for services that are covered under educational Individualized Education Programs (IEP/ISP) or other therapies when duplicative.
Only assessment content addressing core deficits of autism is reimbursable; academic, speech, vocational portions are excluded.
Standardized psychological testing is billed separately with applicable CPT codes by eligible providers.

Documentation Required

Required Clinical Documentation & Failure to Demonstrate Progress

Complete clinical documentation must be submitted by the BCBA/LBA for initial and ongoing requests. Insufficient documentation or failure to demonstrate progress may result in reduced or denied coverage.

Initial assessments must include direct observation and preferred curriculum-based assessments (ABLLS-R, VBMAPP, Vineland, AFLS) with baselines and measurable goals.
Treatment plans must include measurable six-month goals, mastery criteria, data collection, functional behavior assessment (when indicated), documentation of participants, procedures and settings.
If a member fails to demonstrate measurable progress (e.g., mastery of <50% of stated goals across authorization periods) include barriers and revised plan; persistent lack of progress may lead to reduction or denial of benefits.

Billing Rule

Exceeding Standard Assessment/Treatment Hours

Requests that exceed standard assessment or treatment hour limits require additional clinical rationale and will be reviewed by Developmental Pediatrics/TSPMG. Excess hours without justification may be denied.

Assessment: standard maximum is 5 hours (20 units CPT 97151); requests for >5 hours (combined 97151/97152) need extra clinical rationale.
Reassessment: additional clinical rationale required for >5 hours (20 units) for six-month reassessments.
Treatment codes have specific limits (e.g., 97151 max 20 units initial/re-evaluation; 97155 max 20% of total treatment hours; 97156 typical 1–2 hours/week). Concurrent billing restrictions apply (e.g., 97153 and 97155 not approved concurrently).

Prior Authorization

Ordering and Routing

Ordering and routing requirements: ABA may be ordered only by Developmental Pediatrics clinicians. Requests from other providers will be routed to QRM MD for soft denial and follow-up by Developmental Pediatrics.

Only Developmental Pediatrics clinicians may order ABA services.
Requests from pediatricians or other non-Developmental Pediatrics providers should be sent to QRM MD for a soft denial and staff message to the requesting PCP and Developmental Pediatrics team.
Developmental Pediatrics will contact families to determine next steps and may send staff messages to the developmental pool (P DEV).

Denial Risk

Denial Triggers

Denial triggers: requests may be denied for failure to meet QRM medical necessity criteria, age limits, non-contracted providers, lack of required documentation, or insufficient demonstration of progress.

Denial if request does not meet QRM medical necessity criteria or required documentation (including up-to-date diagnostic evaluation and treatment plan) is not provided.
Denial if member exceeds covered age limit (coverage limited through age 20).
Denial for services provided by non-contracted ABA vendors; follow up with Developmental Pediatrics for next steps.

Restricted, repetitive patterns of behavior, interests, and activities

DSM requirementSymptoms present in early development with clinically significant impairment in functioning

Functional Behavior Assessment definition (FBA)

DefinitionFunctional Behavior Assessment (FBA): procedures to identify antecedents and consequences influencing target behaviors via interviews, checklists, rating scales, observation, and recording in everyday situations

ComponentsDescription of topography, onset/offset, cycle, intensity, severity, and antecedent analysis

UseMay be part of any assessment to inform treatment targets and interventions

Caregiver Training (alternate entry)

DefinitionCaregiver‑mediated ABA strategies: education and development of caregiver‑implemented protocols or techniques to facilitate skill acquisition, generalization, and behavior management

ParticipationCaregivers should begin training at service onset and participate in sessions agreed upon with the provider

Dosing recommendationRecommended: 1 hour caregiver training per first 10 direct therapy hours, then 0.5 hours per additional 10 direct hours unless contraindicated or caregiver declines

Clinically Significant

DefinitionClinically Significant: a treatment effect of practical importance that creates a meaningful difference and produces noticeable impact in daily functioning

AssessmentMeasured by adaptive behavior, cognitive, or language testing showing functional improvement rather than decline or plateau

RelevanceSix‑month goals and long‑term objectives should be clinically significant and reasonably expected to be mastered

Core Deficits of Autism (duplicate inventory entry)

Core areasPersistent deficits in social communication and social interaction across multiple contexts

Restricted patternsRestricted, repetitive patterns of behavior, interests, and activities

Functional impactSymptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

Functional Behavior Assessment (duplicate inventory entry)

DefinitionFunctional Behavior Assessment: descriptive procedures to identify environmental events occurring before and after target behaviors via interviews, checklists, questionnaires and observation

Data sourcesInformation may be gathered from caregivers, rating scales, and direct observation/recording of behaviors in everyday situations

PurposeUsed to determine functions of behaviors and inform individualized interventions

Generalization

DefinitionGeneralization: skills acquired in one setting are applied to multiple contexts, stimuli, materials, people, and settings to be practical and functional for the individual

RequirementGeneralization planning should be central to interventions and caregiver training strategies

OutcomeSuccessful generalization increases likelihood of task independence

Paraprofessional Care

DefinitionParaprofessional Care: services provided by unlicensed persons to help maintain behavior programs to support inclusion or independent living goals

LimitationParaprofessional services are subject to state mandates or benefit provisions that may limit coverage

PurposeDesigned to assist implementation and maintenance of behavior programs rather than provide clinical diagnosis or treatment planning

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Functional assessments: Functional Behavior Assessment (FBA) procedures (interviews, checklists, observation, and data recording) are required as clinically indicated to identify antecedents/consequences for target behaviors and to inform behavior intervention planning and progress measurement.

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Caregiver training modality: Caregiver training should begin at the onset of services, be mutually agreed upon between provider and caregiver, and focus on caregiver-mediated ABA strategies, generalization, and treatment integrity; caregiver participation is expected for at least 80% of agreed sessions with recommended dosing (1 hour per first 10 direct therapy hours, then 0.5 hour per subsequent 10 hours) and goals including mastery criteria, data collection and generalization plans.80% participation; dosing per chunk 18

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