Prior authorization required — submit DSM‑concordant diagnosis, baseline data, and ABA treatment plan

Initial and continued ABA services require prior authorization. Submit a request that documents (1) a DSM-based ASD diagnosis with a clinical diagnostic note showing concordance with current DSM criteria, (2) required baseline assessments (developmental/cognitive, autism-specific severity, adaptive behavior within 6 months, neurological exam) completed or scheduled within 90 days and not older than 5 years, and (3) a treatment plan with goals focused on core ASD symptoms, generalization plans, caregiver training or alternate plan, and evidence of clinical benefit/progress for continued treatment.

• Clinical diagnostic note demonstrating concordance with current DSM criteria and ruling out differential diagnoses (ASD-specific standardized assessment required).
• Baseline data: developmental/cognitive evaluation; autism-specific assessment; adaptive behavior assessment (within 6 months of treatment start); neurological evaluation.
• Baseline data must be completed prior to or scheduled within 90 days of the assessment and no older than five years unless indicated.
• Treatment plan must include goals focused on ASD core symptoms, plans for stimulus/response generalization, caregiver training or an alternate generalization plan.
• For continued authorization, document clinical/social benefit, new or continuing goals, and progress evidenced by behavioral change and skill acquisition.

Policy covers ABA only — alternative ASD treatments are outside scope

This policy governs Applied Behavior Analysis services specifically; alternative ASD treatment approaches listed in the policy (e.g., Cognitive Training, Auditory Integration Therapy, Facilitated Communication, music or pet therapy, Sensory Integration Training, and other named programs) are outside the scope of this ABA policy and require consultation with the Service Benefit Plan for coverage determination.

• If requesting coverage for non‑ABA ASD treatments, members/providers should consult the Service Benefit Plan to determine benefit coverage.

Required documentation — submission checklist for authorization

Required documentation to support authorization requests includes a clinical diagnostic note consistent with DSM criteria plus formal assessment reports: autism-specific testing, adaptive behavior testing, cognitive/developmental evaluation, and any psychological testing or neurological evaluation; baseline data must be completed or scheduled within 90 days and adaptive behavior testing must be within six months of treatment start.

• Clinical diagnostic note with sufficient depth to demonstrate concordance with DSM criteria (autism screening results alone are not sufficient).
• Formal reports of autism‑specific assessment, adaptive behavior assessment, and cognitive/developmental evaluation with scores/results.
• Neurological evaluation as part of a comprehensive physical exam when applicable.
• Baseline data timing: completed prior to or scheduled within 90 days of the assessment; adaptive behavior assessment within 6 months of treatment start; no older than 5 years unless indicated.

Denial triggers — common reasons requests are denied

Requests may be denied for common deficiencies including inadequate diagnostic documentation, requests for hours exceeding what is required for the pre‑treatment assessment, or failure to provide required baseline assessments and reports.

• Insufficient diagnostic documentation that does not demonstrate concordance with current DSM criteria (autism screening measures alone are not acceptable).
• Hours requested exceed what is required to complete the pre‑treatment assessment or are not appropriate for the intensity classification.
• Missing baseline data or formal assessment reports (autism‑specific testing, adaptive behavior, cognitive/developmental, neurological evaluation).