Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyLucet ABA Down Syndrome Prior Auth Coverage | Open…
    Ask Trek AI about this page
    CurrentlucetPolicy 20.5.006

    Applied Behavior Analysis for the Treatment of Down Syndrome

    Customize your policy alerts

    Sign up for lucet Policy 20.5.006 alerts

    Get alerted when Policy 20.5.006 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines Lucet's coverage policy, medical necessity criteria, and authorization requirements for Applied Behavior Analysis (ABA) services provided to members diagnosed with Down syndrome (without comorbid ASD). Applies to providers seeking ABA benefit determinations under Lucet-managed plans.

    Policy Summary
    Payerlucet
    PolicyApplied Behavior Analysis for the Treatment of Down Syndrome
    Policy CodePolicy 20.5.006
    Change TypeNo material changes
    Effective DateJan 1, 2017
    Last ReviewJun 28, 2023
    Next Review Date
    Key ActionSubmit prior authorization with required documentation including adaptive behavior and cognitive assessments, baseline data, and a treatment plan to obtain coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Diagnosis-specificpolicy scope
    6 months

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    assessment timing
    2x/yrreview frequency
    FLstate mandate

    Coverage and Medical Necessity Criteria

    Pre-treatment Assessment

    Covered when ALL of the following are met for a pretreatment assessment:

    Pretreatment Assessment Criteria: 1. The member has a diagnosis of Down Syndrome (without a comorbid diagnosis of ASD) from a clinician who is licensed and qualified to make such a diagnosis and confirmed by genetic testing.; 2. Hours requested are not more than what is required to complete the pretreatment assessment.; 3. All assessment services are provided in a manner consistent with the Lucet Provider Manual, the Behavior Analysis Certification Board's Ethics Code for Behavior Analysts or relevant ethics code, generally accepted standards of care, and applicable state laws.

    Initial Treatment

    Initial ABA treatment authorization is covered when ALL of the following are met:

    Initial Treatment Criteria: 1. Diagnostic Criteria as set forth in the previous section are met.; 2. Documentation of psychological assessment, including adaptive behavior testing and cognitive evaluation to define baseline functioning, with a formal report detailing scores and results.; 3. Baseline data completed prior to or scheduled within 90 days of the assessment and no older than 5 years prior to the pre-treatment assessment (includes: a. developmental and cognitive evaluation; b. adaptive behavior assessment completed within 6 months of start date of treatment; c. neurological evaluation as part of a comprehensive physical examination; d. information required by state law).; 4. Approved treatment goals and clinical documentation focused on active symptoms, substantial deficits that inhibit daily functioning, and clinically significant aberrant behaviors requiring the expertise of a Behavior Analyst, including a plan for stimulus and response generalization.; 5. ABA treatment is not designed to attain academic performance.; 6. ABA treatment is not a substitute for psychotherapy, occupational therapy, or other medical or behavioral health services.; 7. Ongoing, detailed, individualized coordination of care, safety planning, and discharge planning are conducted as part of treatment planning.; 8. Treatment goals are either comprehensive (to reduce the gap between chronological and developmental ages and restore function) or focused (to reduce burden of targeted symptoms and increase appropriate alternative behaviors).; 9. Treatment is provided in the setting and intensity appropriate for the member's clinical needs, determined by where target behaviors occur and where treatment is likely to impact those behaviors.; 10. Services are provided consistent with the Lucet Provider Manual, the BACB Ethics Code for Behavior Analysts or relevant ethics code, generally accepted standards of care, and applicable state laws.; 11. The treatment plan includes a plan to support generalization of skills across stimuli, contexts, and individuals via caregiver training or an appropriate alternative, including demonstration of how instructional control will be transferred to caregivers and an alternate plan if caregiver involvement is unsuccessful.Adaptive behavior assessment must be completed within 6 months of the start date of treatment; baseline data no older than 5 years and baseline elements must be completed prior to or scheduled within 90 days of the assessment.

    Continuation Treatment

    Continued ABA treatment authorization is covered when ALL of the following are met:

    Continued Treatment Criteria: 1. Criteria 1-11 in the Initial ABA Treatment Authorization Request section are met.; 2. Provider demonstrates: a. documentation of clinical or social benefit to the child from treatment; b. identification of new or continuing treatment goals; c. development of a new or continuing treatment plan based on progress evidenced by the member's behavioral changes and increased skill acquisition.

    Treatments other than Applied Behavior Analysis (ABA) are outside the scope of this policy and are not governed here. Examples of alternative approaches not contemplated by this policy 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, Holding Therapy, Movement Therapy, Music Therapy, Pet Therapy, Psychoanalysis, Son-Rise Program, Scotopic Sensitivity Training, Sensory Integration Training, and Neurotherapy (EEG biofeedback). Members should consult their Service Plan Description to determine benefit coverage for non-ABA treatments for Down syndrome.

    ABA services for members with Down syndrome are intended to address adaptive skills, reduce clinically significant aberrant behaviors, and close developmental gaps — they are not designed to attain academic performance. Additionally, ABA is not a substitute for psychotherapy, occupational therapy, or other medical or behavioral health services; requests must demonstrate that ABA targets functional deficits or behaviors requiring the expertise of a Behavior Analyst rather than serving as a replacement for these other therapies.

    Coding, Assessments, and Timing Requirements

    No codes listedmixed
    No codes listed
    inv-07: Adaptive behavior assessment timing
    RequirementAdaptive behavior assessment must be completed within 6 months of the start date of treatment.
    PurposeDefines baseline adaptive functioning to guide individualized treatment planning and goal setting.
    DocumentationAssessment should be accompanied by a formal report detailing scores and results.
    inv-08: Baseline data recency
    RequirementBaseline data must have been completed no longer than 5 years prior to the pre-treatment assessment.
    Included Baseline DataDevelopmental and cognitive evaluation; adaptive behavior assessment; neurological evaluation; information required by state law.

    Provider Requirements, Documentation, and Authorization

    Prior Authorization

    Prior authorization required for pretreatment, initial, and continued authorizations

    Pre-treatment assessment, initial ABA treatment authorization, and continued ABA treatment authorization each require prior review and must meet the policy's listed criteria, including confirmed diagnosis, baseline assessments, treatment goals, and provider qualifications.

    • Pre-treatment assessment requests must meet all pretreatment criteria (diagnosis confirmed by genetic testing; hours requested not excessive; assessments consistent with Lucet Provider Manual/BACB Ethics/state laws).
    • Initial authorization must include diagnostic criteria, psychological assessment with adaptive behavior testing and cognitive evaluation, baseline data, approved treatment goals, and provider adherence to standards of care.
    • Continued authorization requires maintenance of initial criteria plus documentation of clinical or social benefit, new/continuing goals, and an updated treatment plan based on progress.
    Note

    Provider-level staffing expectations for line therapy

    Line therapy staffing must follow state law when present; when no state law applies, line therapy should be provided by a Registered Behavior Technician (RBT), Board Certified Assistant Behavior Analyst (BCaBA), or a Master's/Doctoral level Board Certified Behavior Analyst (BCBA).

    Clinical Background

    Down syndrome (also known as Trisomy 21) is a genetic condition in which an individual has extra chromosomal material — typically an additional copy of chromosome 21 — that alters physical and brain development. This can produce characteristic physical features and is associated with developmental differences including delayed language development and variable intellectual disability, with IQ commonly in the mildly-to-moderately low range. There is substantial individual variability in presentation and functioning across persons with Down syndrome.

    Definitions

    inv-15: Applied Behavior Analysis (ABA) — definition and key characteristics
    DefinitionApplied Behavior Analysis (ABA) is a behaviorally based treatment framework that is applied, analytic, technological, conceptually systematic, effective, and focused on generalized outcomes.
    Key CharacteristicsInvolves a structured environment, predictable routines, individualized treatment, transition and aftercare planning, and family involvement.
    GoalsAims to increase adaptive skills and reduce behavioral excesses, eliminating barriers to learning and improving daily functioning.
    Assessment RolePre-treatment assessment and Functional Behavioral Assessment (FBA) guide treatment planning, target behaviors, and progress monitoring.
    inv-16: Down syndrome — definition (Trisomy 21) and brief description
    Definition
    Policy Summary
    Payerlucet
    PolicyApplied Behavior Analysis for the Treatment of Down Syndrome
    Policy CodePolicy 20.5.006
    Change TypeNo material changes
    Effective DateJan 1, 2017
    Last ReviewJun 28, 2023
    Next Review Date
    Key ActionSubmit prior authorization with required documentation including adaptive behavior and cognitive assessments, baseline data, and a treatment plan to obtain coverage.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCoding, Assessments, and Timing RequirementsProvider Requirements, Documentation, and AuthorizationClinical BackgroundDefinitions
    ApplicationApplies to baseline data submitted with initial ABA treatment authorization requests.
    inv-09: Scheduling of baseline data
    RequirementBaseline data must be completed prior to or scheduled within 90 days of the assessment.
    What to ScheduleDevelopmental/cognitive evaluation, adaptive behavior assessment, neurological evaluation, and state-required information as applicable.
    Effect on AuthorizationInitial treatment authorization requires these baseline data to be completed or scheduled as specified to meet coverage criteria.
    • If state law prescribes staffing, follow that law.
    • Absent state law, use RBT, BCaBA, or Master's/Doctoral BCBA for line therapy services.
    • Providers must deliver services consistent with the Lucet Provider Manual and BACB Ethics Code or relevant ethics code.
    Documentation Required

    Required documentation to support authorization requests

    Providers must submit psychological assessment reports (including adaptive behavior testing and cognitive evaluation with a formal report), baseline data (developmental/cognitive evaluation; adaptive behavior assessment within 6 months of treatment start; neurological evaluation), approved treatment goals, and documentation of progress for continued authorization.

    • Psychological assessment with formal report detailing scores and results (adaptive behavior testing and cognitive evaluation).
    • Baseline data completed prior to or scheduled within 90 days and no older than 5 years; adaptive behavior assessment must be within 6 months of treatment start.
    • Neurological evaluation as part of a comprehensive physical exam and any information required by state law.
    • For continuation, documentation of clinical/social benefit, identification of new/continuing goals, and a treatment plan reflecting progress.
    Denial Risk

    Denial risks if benefits or medical necessity criteria are not met

    Requests may be denied if benefits are not available in the member's contract/certificate or if medical necessity criteria and the policy's requirements are not met; pretreatment, initial, or continued requests lacking required diagnosis, baseline assessments, documentation, or that exceed necessary hours risk denial.

    • Denial triggers include absence of plan benefits or failure to meet medical necessity criteria and guidelines.
    • Pretreatment assessment requests can be denied for lack of confirmed Down syndrome diagnosis or for requesting more hours than needed to complete the assessment.
    • Initial or continued treatment requests may be denied if baseline assessments, adaptive behavior testing, cognitive evaluation, or other required documentation are missing or out of specified timeframes.
    Down syndrome is a genetic condition in which a person has extra chromosomal material; most commonly each cell has three copies of chromosome 21 (Trisomy 21).
    Clinical FeaturesCan include characteristic facial features, hypotonia (poor muscle tone), short stature, and developmental delays with variable cognitive profiles and delayed language development.
    TypesThree types: Trisomy 21 (about 95%), Translocation Down syndrome (~3%), and Mosaic Down syndrome (~2%).