Prior authorization required for ABA evaluation, initial course, and recertifications

Prior authorization (precertification) is required for an ABA evaluation (CPT 97151), the initial course of ABA treatment, and for recertifications/continued treatment (CPTs 97153, 97154, 97155, 97156, 97158). The policy lists additional CPT, T‑codes and HCPCS codes applicable to ABA services.

• Prior auth applies to procedure code 97151 (behavior identification assessment).
• Prior auth applies to initial and recertification codes including 97153, 97154, 97155, 97156, 97158.

Precertification plus continued-authorization documentation and limits

Prior authorization and continued authorization require submission of the initial assessment and individualized treatment plan; recertifications may be authorized for up to 180 days contingent on required progress and attendance documentation, and continued authorization hours are adjusted based on clinical justification.

• Continued authorization may be adjusted (up or down) based on clinical justification.
• Subsequent authorizations may be approved for up to 180 days when attendance log and progress summary support extension.

Step therapy: none specified

No step therapy protocols are specified in this policy portion.

Clinical/peer review for requests exceeding supported hours

Requests for hours beyond those supported by submitted clinical information may be referred for further clinical review; continued authorization hours may be adjusted up or down based on clinical justification and may require medical director or clinical consultant review for higher-hour requests.

• Maximum typical authorizations: up to 30 hrs/week for Comprehensive ABA (<2 years) or up to 25 hrs/week for Focused ABA for up to 6 consecutive months; requests exceeding available support may prompt additional review.

Documentation required at initiation and for recertification

Providers must submit a signed and dated referral from the prescribing provider specifying frequency and duration; a complete developmental history (comorbidities, vision/hearing screening, one-on-one observations including at least one natural setting, caregiver interviews, family history, primary language, prior ABA history and response); prognosis and a standardized functional assessment performed within the past 12 months.

• Signed, dated referral from physician with recommended frequency and duration.
• Developmental history: comorbid conditions, vision/hearing screening as appropriate, one-on-one and natural-setting observations, caregiver interviews, family history, primary language, prior ABA history and response.
• Standardized functional assessment (e.g., VABS-3, ABAS, VB-MAPP, ABLLS) demonstrating ≥1 SD below mean or significant risk of harm.

Required content of ABA assessment and treatment plan (LBA)

Initial ABA assessments and individualized treatment plans completed by the LBA must include patient identifiers, the date of the initial evaluation/treatment plan, the referring prescribing provider, BT/LBA signature with date, parent/caregiver signature with date, and specific, measurable treatment goals tied to health, safety, or independence and to DSM core ASD symptoms.

• Required elements: child/youth name and DOB; date initial ABA evaluation and treatment plan completed; name of referring prescribing provider; BT/LBA signature with date; parent/caregiver signature with date.
• Treatment plan must identify specific targeted behaviors/skills tied to health, safety, or independence and include measurable, DSM-core-symptom-related goals developed with caregivers.

Recertification documentation: re-evaluation, repeated assessments, attendance, progress summary

For recertification, providers must submit a re-evaluation of interventions and progress performed every six months, a repeated validated assessment every 6–12 months (e.g., Vineland, ABAS, VB‑MAPP, ABLLS), an attendance log with percent of completed scheduled sessions, and a progress summary documenting improvement or treatment modification.

• Re-evaluation of interventions/progress every 6 months.
• Repeated validated assessment every 6–12 months to demonstrate response.
• Attendance log including calculation of percent of scheduled sessions completed and progress summary to support extension.

Requirements for technician-delivered behavior identification and treatment

Behavior identification and adaptive behavior treatment activities delivered by technicians require on‑site administration by the physician or other qualified healthcare professional, with assistance of two or more technicians and completion in an environment customized to the patient's behavior for patients exhibiting destructive behavior.

• Administration must be by a physician or other qualified healthcare professional who is on site.
• Assistance by two or more technicians is required for applicable assessments/treatments for destructive behavior.
• Environment must be customized to the patient's behavior.

Denial triggers: missing precertification elements, outdated/no ASD diagnosis reconfirmation, incomplete assessments

Triggers for denial include requests missing required precertification elements, absence of an appropriate DSM‑5 ASD diagnosis or failure to reconfirm diagnostic criteria when the diagnosis is more than 3 years old, missing documentation of target behaviors or caregiver engagement, or absence of required assessment elements demonstrating functional impairment.

• Missing required precertification elements or assessments may lead to denial.
• ASD diagnosis must be within past 3 years or reconfirmed; otherwise request may be denied.
• Lack of documentation of target behaviors, caregiver engagement, or standardized functional impairment can trigger denial.

Attendance requirement (85%) and documentation impact on recertification

Recertification requests that do not meet the minimum attendance threshold (85% of scheduled sessions agreed within the approved plan) must include additional documentation and be sent for physician review; failure to meet 85% may result in not continuing the previously approved frequency/duration.

• Minimum expected attendance for recertification is 85% of agreed sessions.
• If attendance <85%, submit additional documentation and the request will undergo physician review; continuation at prior frequency/duration is not guaranteed.