CurrentOptumPolicy N/A

Applied Behavior Analysis (ABA) Treatment Reviews Via Portal

Guidance for clinical review requests and required information when seeking authorization for ABA services, including required demographic, diagnostic, service, and clinical progress details; applies to providers submitting reviews via the portal.

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) Treatment Reviews Via Portal

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests with specified ABA procedure codes, the number of hours requested, and supporting clinical documentation demonstrating medical necessity and treatment goals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15example CPT/HCPCS codes listed for request

6 monthstypical review frequency

per 15 min.codes billed in

Coverage Criteria

General approval criteria

Covered when ALL of the following are met:

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) Treatment Reviews Via Portal

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing and Codes

ABA Procedure CodesCPTCovered

97151	Behavior identification assessment, by professional
97152	Behavior identification supporting assessment, by one technician, under direction of professional
0362T	Behavior identification supporting assessment, by technician, requiring administration by professional on site, with assistance of two or more technicians, for patient with destructive behavior, in customized environment
97153	Adaptive behavior treatment by protocol, by technician under direction of professional
0373T	Adaptive behavior treatment with protocol modification, by technician, requiring administration by professional on site, with assistance of two or more technicians, for patient with destructive behavior, in customized environment
97154	Group adaptive behavior treatment by protocol, by technician under direction of professional
97155	Adaptive behavior treatment with protocol modification, by professional
97156	Family adaptive behavior treatment guidance, by professional (with or without patient present)
97157	Multiple-family group adaptive behavior treatment guidance, by professional (without patient present)
97158	Group adaptive treatment with protocol modification, by professional

inv-05: billing unit — per 15 min.

Billing unitPer 15-minute unit

How to report unitsReport each listed ABA procedure code in 15-minute units when requesting treatment hours

Provider instructionSpecify number of hours per week, month, or total for each code requested

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for ABA services. When requesting treatment hours, use the listed billing codes and specify the number of hours requested (per week, per month, or total) for each code. Requests must include supporting clinical documentation as described in the documentation requirements.

Use the billing codes below (code values are per 15-minute unit) when requesting treatment hours and indicate number of hours per week/month/total for each code: 97151, 97152, 0362T, 97153, 0373T, 97154, 97155, 97156, 97157, 97158.
Include the number of units/hours requested for each specific code.
Submit prior authorization requests with all supporting clinical documentation (demographics, diagnostic information, assessments, treatment plan, progress data, and progress notes).
Approvals are based on medical necessity for specific treatment goals addressing defined behavioral targets; requests lacking demonstrated medical necessity may be denied.

Denial Risk

Medical Necessity Requirement

All requests for ABA treatment must demonstrate medical necessity tied to specific treatment goals and behavioral targets. If the request does not show how proposed services address the individual's identified deficits, progress, or treatment goals, the request may be denied. Providers should document the rationale for the level and type of services requested and include evidence of ongoing monitoring and modification of treatment based on progress.

Medical necessity must be supported by: diagnostic information (e.g., ASD diagnosis, diagnosing clinician and date), relevant assessments and scores (e.g., Vineland, VB-MAPP, ABLLS), current symptoms, severity ratings across communication, social, behavior domains, and maladaptive behavior severity.
Treatment plan must include: specific goals/objectives/targets, service modalities, frequency and duration (hours per week/month/total by CPT code), caregiver involvement and training, and measurable progress data.
Progress reviews and supporting clinical updates should be submitted at least every 6 months (or per state/account requirements) and must reflect changes in goals, new targets, and modifications based on the individual's progress or life changes.
Denials may be issued when documentation does not establish that requested services are reasonably expected to improve functional outcomes or when goals/targets are not specific and measurable.

Background

Applied Behavior Analysis (ABA) is used to address deficits associated with Autism Spectrum Disorder and related behavioral and communication impairments. Review of ABA treatment requests focuses on documentation of baseline functioning, specific treatment goals, objectives and targets, relevant assessment data, and ongoing progress monitoring. Supporting clinical updates are expected to track progress across all areas of functioning, reflect any major life changes, and describe modifications to treatment and addition of new goals as indicated. Reviews of supporting clinical updates are performed at a frequency required by state or account requirements, ordinarily 6 months. All approval requests for treatment are based on demonstration of medical necessity for specific treatment goals that address identified behavioral targets.

Definitions and Severity Categories

inv-12: Social communication severity — Mild/Moderate/Severe per DSM-5 functional impacts

Mild social communication severityWithout supports, deficits cause noticeable impairment to a trained observer; challenges with back-and-forth conversation, failed attempts to communicate, unusual or atypical communication

Moderate social communication severityMarked deficits in communication skills that are apparent even with supports in place; markedly odd nonverbal communication

Severe social communication severitySevere deficits in verbal and nonverbal communication, often limited or no speech

Other required detailsReport mode of communication (e.g., verbal, sign, device), main goals, total number of goals, and progress including goals mastered

inv-13: Behavioral severity / maladaptive behaviors — Mild/Moderate/Severe frequency and functional interference descriptors

Mild behavioral severityInflexibility causes interference with functioning in one or more contexts; difficulty switching tasks; impacts are small to the individual’s overall day

Moderate behavioral severityDifficulty coping with change; behaviors obvious to casual observers; interfere with functioning in various contexts; distress occurs when changing actions or focus

Severe behavioral severityExtreme difficulty coping with change; marked interference with functioning in all spheres; great distress with changes and severe impact on daily functioning

Maladaptive behaviorsClassify aggression, self-injury, or other maladaptive behaviors as mild, moderate, or severe and report frequency and functional interference

ABA Review Standards

ABA review standards

General standards referenced for ABA code approvals and review frequency

Initial plan content: Initial plan should document baseline areas, goals, objectives, targets, and applicable assessments; new goals added as indicated

See chunk 11

Review frequency: Supporting clinical updates reviewed ordinarily every 6 months or per state/account requirements6 months

See chunk 11

ABA Assessment and Treatment Modalities

ABA (assessment and treatment; technician and professional delivered)

Modality: Technician-delivered ABA: Use CPT/CAT II codes for assessment and adaptive behavior treatment (e.g., 97151, 97152, 0362T, 97153, 0373T, 97154, 97155, 97156, 97157, 97158) billed in 15-minute units; requester must specify number of hours per week, month, or total for each code and provide documentation supporting medical necessityper 15 min.

See chunk 2 and chunk 11

Visit Limits & Units

inv-17: Codes billed in 15-minute units; requester must specify hours per week/month/total for each code

Required code reporting formatList each ABA procedure code and specify the number of hours requested per week, per month, or total; codes are billed in 15-minute units

Common ABA procedure codes97151, 97152, 0362T, 97153, 0373T, 97154, 97155, 97156, 97157, 97158

Code 97151 descriptionBehavior identification assessment, by professional

Code 97153 descriptionAdaptive behavior treatment by protocol, by technician under direction of professional

Codes for destructive behavior with on-site professional0362T and 0373T are for assessments/treatment requiring professional on site with assistance of two or more technicians in a customized environment

OpenPayer