Updated Clinical Criteria for ABA and TMS Services
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Defines the clinical guidelines Optum will use to determine medical necessity for Applied Behavior Analysis (ABA) and Transcranial Magnetic Stimulation (TMS) for Commercial members in Colorado beginning May 15, 2026.
Optum Behavioral Health will use independent, nationally recognized clinical guidelines developed by nonprofit organizations to evaluate medical necessity for ABA and TMS services for Commercial members in Colorado.
ABA services will be evaluated using Council of Autism Service Providers (CASP) guidelines.
TMS services will be evaluated using CANMAT (2016 and 2023 editions) and the APA Position Statement on TMS.
Coverage Criteria and Scope
Coverage criteria tied to external guidelines
Covered when service medical necessity is consistent with the specified guideline sources
Document references guideline sources but does not enumerate specific clinical entry/continuation criteria.
The updated clinical criteria apply only to Applied Behavior Analysis (ABA) and Transcranial Magnetic Stimulation (TMS) services for Commercial members in Colorado. Providers should note that all other behavioral health clinical criteria remain unchanged and continue to follow the existing, previously published standards.
Services for ABA or TMS that do not meet the requirements of the specified independent, nonprofit guideline sources may be considered not medically necessary. Specifically, medical necessity determinations for ABA reference the Council of Autism Service Providers (CASP) guidance, and TMS determinations reference the CANMAT (2016 and 2023) guidelines together with the APA Position Statement on TMS; failure to meet those guideline-based requirements may result in services being denied as not medically necessary.
Applied Behavior Analysis (ABA) Criteria
ABA guideline source
ABA medical necessity determinations will reference the CASP guidelines.
Specific CASP criteria are not reproduced in this document.
Transcranial Magnetic Stimulation (TMS) Criteria
TMS guideline source
Specific treatment indications, parameters, and course-of-treatment criteria are referenced to those sources and not reproduced here.
Provider Requirements and Prior Authorization
Prior Authorization Required
Prior authorization and medical necessity reviews for ABA and TMS for Colorado Commercial members will use the specified independent nonprofit clinical guidelines effective May 15, 2026. Providers must submit prior authorization requests following Optum's standard PA process and reference the updated guideline source in the request.
- Applied Behavior Analysis (ABA): Council of Autism Service Providers (CASP) guidelines
- Transcranial Magnetic Stimulation (TMS): CANMAT 2016, CANMAT 2023, APA Position Statement on TMS
Guideline Alignment
Services that are not supported by the listed independent nonprofit clinical guidelines for ABA and TMS may be denied or considered not medically necessary. This alignment applies only to ABA and TMS for Commercial members in Colorado; other behavioral health criteria remain unchanged.
- Policy impact limited to ABA and TMS for Colorado Commercial members
- Other existing criteria (ASAM, LOCUS, CALOCUS-CASII, APA testing guidance) remain in effect
Provider Documentation Expectations
Providers should update their practice guidelines and clinical documentation to demonstrate alignment with the cited nonprofit guidelines. Include specific citations to the guideline edition(s) used and relevant clinical findings that meet the guideline-based medical necessity criteria when submitting authorizations or claims.
- Update practice protocols to reflect CASP for ABA and CANMAT/APA for TMS
- Document guideline edition, relevant clinical criteria met, treatment plan, and prior response to therapies in the medical record
- Reference guideline sources in prior authorization requests and clinical notes
Provider Requirements (Action Needed)
Providers must take action to ensure compliance with the updated criteria: review the listed guideline sources, revise internal practice guidance, and incorporate the guideline citations into all future PA submissions for Colorado Commercial members receiving ABA or TMS.
- Review CASP guidelines for ABA
- Review CANMAT (2016 and 2023) and APA Position Statement for TMS
- Apply these guidelines for medical necessity determinations and authorizations for Colorado Commercial members
Definitions and Guideline Sources
Policy Background and Legal Context
Colorado law (Colorado Revised Statutes § 10-16-104 (5.5) and 3 CCR 702-4 Regulation 4-2-64) requires health plans to use independent, nationally recognized clinical guidelines developed by nonprofit organizations when making coverage and utilization review decisions. Optum Behavioral Health updated its clinical criteria to comply with this requirement and has identified the nonprofit guideline sources that will be used to evaluate medical necessity for ABA and TMS effective May 15, 2026.
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