Clinical Review Criteria: Applied Behavioral Analysis (ABA) Therapy
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Clinical review criteria governing preauthorization, provider qualifications, documentation, and medical necessity determinations for ABA therapy for Kaiser Foundation Health Plan of Washington members (non‑Medicare and Medicare sections noted). Applies to providers requesting ABA benefits under Kaiser Permanente WA plans.
Effective September 1, 2026, language updates clarify treatment hour authorization (higher hours may be authorized for unsafe behavior) and strengthen documentation and progress-reporting requirements.
MPC approved an update to criterion 8. 60-day notice required, effective 09/01/2026.
Updated applicable coding to exclude H2017, 0362T, and 0373T and clarified ABA reimbursable services.
MPC approved the criteria updates to add clarifying language on coverage (60-day notice, effective March 1, 2024).
Coverage and Medical Necessity Criteria
Initial Authorization
Covered when ALL of the following are met
Six to 10 hours usually sufficient for ITP development unless clinical complexity justifies more.
Continued Therapy Authorization
Covered to continue when ALL of the following are met
Intensity and Duration
Treatment amount guidance
Coverage rationale and evidence summary
Coverage is conditional — ABA/EIBI is considered medically necessary when the policy's clinical criteria are met and documentation/authorization requirements fulfilled.
The policy lists specific activities and situations that are not medically necessary for ABA services. These exclusions include: more than one program manager/lead behavioral therapist for the member at any one time and more than one agency/organization providing ABA services concurrently for the same member. Services that duplicate school IEP obligations when those services are the responsibility of the school are not considered medically necessary. Routine non‑ABA activities (for example, taking the patient to community outings, tutoring/assisting with academic work, or performing household chores) are excluded unless the activity directly involves treatment of behavior specified in the ITP (e.g., documented pattern of significant behavioral difficulty during that activity or a specific skill targeted in the plan). Custodial or respite‑type care and activities that do not constitute application of applied behavioral analysis techniques may be denied as non‑covered.
The Medical Technology Assessment Committee (MTAC) evaluated the ABA/EIBI literature and concluded that the body of evidence does not meet Kaiser Permanente’s MTAC criteria for a broad, unconditional recommendation. The search identified approximately 100 articles, multiple systematic reviews and meta-analyses, and a small randomized trial (Early Start Denver Model, N=48), but MTAC found the evidence insufficiently robust to support universal endorsement of ABA/EIBI without criteria‑based limitations.
Continuation of ABA services requires documentation of ongoing, measurable functional progress. The policy specifies that if a patient fails to make functional progress across consecutive ITPs (for example, not meeting the majority of ITP goals and not showing increased participation in home/school/community activities or reduced safety risk) and there is no reasonable expectation of further progress, then further ABA services are not medically necessary and should not be continued.
MTAC and the policy authors caution about limitations in the evidence base: studies are often small, heterogeneous in methods and interventions, include limited randomized data, and have relatively short follow‑up. Because of these limitations, the policy frames coverage as conditional and criteria‑based rather than universally prescriptive; it warns against assuming long‑term durability or generalizability of reported effects across all ABA/EIBI approaches.
Billing and Code Guidance
| 97151 | Behavior Identification Assessment, administered by QHP, each 15 minutes of QHP's time face -to-face with patient and/or guardian(s)/caregivers(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. |
| 97152 | Behavior Identification Supporting Assessment, administered by one technician under the direction of QHP, face-to-face with the patient, each 15 minutes. |
| 97153 | Adaptive Behavior Treatment by Protocol, administered by technician under the direction of a QHP, face-to-face with one patient, each 15 minutes. |
| 97153 w/HO | 97153 w/HO modifier, Description = . |
| 97154 | Group Adaptive Behavior Treatment by Protocol, administered by technician under direction of QHP, face-to-face with 2+ patients, each 15 minutes. |
| 97155 | Adaptive Behavior Treatment with Protocol Modification, administered by QHP, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. |
| 97156 | Family Adaptive Behavior Treatment Guidance, administered by QHP (with or without patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. |
| 97157 | Multiple-Family Group Adaptive Behavior Treatment Guidance, administered by QHP (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes. |
| 97158 | Group Adaptive Behavior Treatment with Protocol Modification, administered by QHP face-to-face with multiple patients, each 15 minutes. |
| 97151 | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. |
| 97152 | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or qualified health care professional, face-to-face, each 15 minutes. |
| 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or qualified health care professional, face-to-face with one patient, each 15 minutes. |
| 97153 HO Modifier | Adaptive behavior treatment by protocol, administered by physician or other qualified health professional, face-to-face with one patient. |
| 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or qualified health care professional, face-to-face with two or more patients, each 15 minutes. |
| 97155 | Adaptive behavior treatment with protocol modification, administered by physician or qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. |
| 97156 | Family adaptive behavior treatment guidance, administered by physician or qualified health care professional (with or without patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. |
| 97157 | Multiple-family group adaptive behavior treatment guidance, administered by physician or qualified health care professional (without patient present), face-to-face with multiple guardian/caregiver sets, each 15 minutes. |
| 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or qualified health care professional, face-to-face with multiple patients, each 15 minutes. |
Authorization, Documentation, and Provider Requirements
Prior Authorization Required
ABA requires preauthorization for initial and continued therapy. The lead behavioral therapist must be a board-certified behavior analyst (BCBA) and providers must meet Plan credentialing and contracting requirements. Verify authorization requirements for specific CPT codes using the Pre-authorization Code Check.
- Applies to all Kaiser Permanente plans with a benefit (except Microsoft)
- Lead behavioral therapist: BCBA required
- Provider credentialing: individual licensure and Plan credentialing/contracting OR employment by an approved healthcare delivery organization with Plan credentialing
- Use Pre-authorization Code Check to verify code-specific requirements
Authorization Required for ABA CPT Codes
Prior authorization/verification is required for ABA CPT codes. Failure to obtain required authorization may result in nonpayment. Use the Plan's Pre-authorization Code Check tool to confirm whether a requested CPT code requires preauthorization under the member's specific plan.
- CPT codes include 97151–97158 (see policy coding section)
- Verify authorization requirements by plan type prior to scheduling services
Prior Less‑Intensive Intervention Requirement
Document attempts at less‑intensive or less‑intrusive interventions and that they were unsuccessful or not available before initiating ABA. The Initial Treatment Plan (ITP) must describe how prior interventions were tried and why ABA is indicated.
- Document prior behavioral interventions and why they were ineffective
- ITP should review school-based IEPs and other community services and explain why ABA does not duplicate those services
Provider Requirements
Follow provider qualifications, supervision, and documentation requirements in the policy. Ensure only one program manager/lead behavioral therapist and one agency provide ABA services to a member at a time unless otherwise authorized.
- Lead behavioral therapist must be a BCBA
- Clinical supervision for unlicensed staff must include bimonthly (every 60 days) ITP approval and case review
- On-site supervision: at least one hour of on-site observation for every 40 hours of member services
Required Clinical Documentation
Submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity. Include complete ITPs, assessment reports, and data that demonstrate functional impact and ongoing progress.
- Include standardized assessment results and ITP reviews
- Provide documentation showing how behaviors impact home, school, or community participation
Documentation Deficiency
All ABA visits must be documented with sufficient detail to verify medical necessity and track progress. Documentation deficiencies may prevent verification of medical necessity and block authorization or payment.
- Document who was present, visit duration, targeted behavior, procedures/interventions used, response to intervention, intervention format, and plan for next visit
- Include graphical or numerical data/behavior tracking sheets and signature, title, and credentials of person completing documentation
- Failure to submit the last 6 months of clinical notes or requested supporting documentation may result in denial or inability to verify medical necessity
Clinical Background and Evidence Context
Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental condition characterized by deficits in communication, social interaction, and restricted or repetitive behaviors. Early diagnosis and timely intervention can improve functional outcomes. Applied Behavioral Analysis (ABA) and Early Intensive Behavioral Intervention (EIBI) are behavioral treatment approaches based on learning principles (reinforcement, extinction, stimulus control and generalization) that use individualized, structured programs, data‑driven progress monitoring, and parent/caregiver training. The policy recognizes that ABA/EIBI programs vary in intensity and format (from focused, targeted interventions to comprehensive early intensive programs) and that program features such as early start, individualized goals, and caregiver coaching inform medical necessity determinations and authorization requirements.
Key Definitions
Service Setting and Level of Care
Outpatient/Community‑based ABA
Admission and participation requirements for community/outpatient ABA
Outpatient/Intensive Outpatient
Delivery ranges from intensive home‑based EIBI to clinic‑based services; intensity and structure vary by need
ABA-Specific Clinical Criteria
ABA clinical criteria
ABA covered when assessment, ITP, provider qualifications, and documentation requirements are met
Program features informing ABA coverage criteria
Policy highlights typical ABA program features and notes recent updates to clinical and provider language; these features inform coverage criteria
These program features inform clinical criteria for coverage and were reviewed by MTAC and the Medical Policy Committee in multiple revisions.
Therapy Types and Modalities
Caregiver coaching/Family training
Caregiver coaching is required and integrated into the ITP
ABA/EIBI modalities
Program modalities described; intensity and structure vary by clinical need and evidence base
Intensity, Frequency, and Visit Limits
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