CurrentOptumPolicy BH803LA082025

Louisiana Medicaid Applied Behavior Analysis (ABA) - State-Specific Clinical Criteria

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State-specific clinical criteria governing medical necessity, prior authorization, assessment, treatment planning, supervision, service delivery, limitations, and telehealth for ABA services for Louisiana Medicaid beneficiaries under age 21.

Policy Summary

PayerOptum

PolicyLouisiana Medicaid Applied Behavior Analysis (ABA) - State-Specific Clinical Criteria

Policy CodePolicy BH803LA082025

Change TypeMaterial additions and clarifications

Effective DateJan 1, 2025

Last ReviewAug 19, 2025

Next Review DateAug 19, 2025

Key ActionObtain two-stage prior authorization: one for the comprehensive assessment and behavior treatment plan and a separate authorization for ongoing ABA therapy, with required PA documentation attached.

SourceLink

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CurrentOptumPolicy BH803LA082025

Louisiana Medicaid Applied Behavior Analysis (ABA) - State-Specific Clinical Criteria

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Policy Summary

PayerOptum

PolicyLouisiana Medicaid Applied Behavior Analysis (ABA) - State-Specific Clinical Criteria

Policy CodePolicy BH803LA082025

Change TypeMaterial additions and clarifications

Effective DateJan 1, 2025

Last ReviewAug 19, 2025

Next Review DateAug 19, 2025

SourceLink

POLICY UPDATE CHANGES

Added MCHAT-R/F guidance allowing pediatricians to diagnose autism with a high-risk score (≥8) and guidance for moderate risk (3-7).

Added explicit telehealth allowances and list of ABA codes that may be performed via telehealth.

Prior authorization process defined as two-fold: one authorization for assessment and treatment plan development and a second for ongoing therapy.

180 daysmaximum prior authorization period

under 21beneficiary age limit for ABA services

2:10supervision ratio

24max technicians supervised/day

97151-97158ABA codes allowed via telehealth

Coverage and Medical Necessity Criteria

Initial Coverage Criteria

Covered when ALL of the following are met:

Beneficiary eligibility: Recipient under age 21

See Beneficiary Requirements

Problem behaviors and diagnosis: Exhibits excesses and/or deficits of behaviors that significantly interfere with home or community activities (e.g., aggression, self-injury, elopement) AND has a diagnosis for which ABA-based therapy is therapeutically appropriate (including autism spectrum disorder) documented by a Qualified Health Care Professional (QHCP)

Comprehensive Diagnostic Evaluation (CDE): CDE completed by a Qualified Health Care Professional per policy definitions and including clinical history, direct observation, review of records, DSM-5 diagnosis, justification for ABA referral, and recommendations

CDE must be attached to prior authorization; pediatrician MCHAT-R/F guidance applies

Prescription/Order: Prescription or order for ABA-based therapy services by a Qualified Health Care Professional (unless the CDE explicitly recommends ABA, in which case a separate prescription is not required)

Assessment, Treatment Plan, and Supervision Criteria

Requirements for assessment, plan, and supervision

Functional assessment and treatment plan: Licensed supervising professional must perform a functional assessment using outcomes from the CDE and develop a behavior treatment plan; 'Behavior Identification Assessment' and supporting assessments require prior authorization and authorization periods shall not exceed 180 days180 days for authorization period

Additional assessment may be authorized in exceptional circumstances

Behavior treatment plan content: Behavior treatment plan must be person-centered with behaviorally defined long-, intermediate-, and short-term goals; identify measurement criteria, schedule (hours/week) and locations, individual providers, justification for intensity/frequency, evidence that direct observation occurred, care coordination, and parent/caregiver training and support

Providers may use LDH template or equivalent; missing information may delay PA

Supervision: Licensed supervising professional provides case oversight, regular family meetings, on-site supervision in presence of beneficiary and non-licensed staff, and must not bill supervision when delivering direct therapy; supervision approved at 2 hours per 10 hours of therapy

Service Delivery Criteria

Service delivery conditions

Place and modality of service: Services must be provided in natural settings (home, community, clinic, school); medically necessary ABA services in school settings are allowed; group and multiple-family formats are allowed when included in the approved behavior treatment plan

Registered line technician group and adaptive behavior social skills groups require two or more beneficiaries with similar needs

Family involvement: Treatment plans must include parent/caregiver training, support, participation, and care coordination; 'Family' and 'Multiple-family' adaptive behavior treatment guidance should be included in the plan for prior authorization to transfer skills to caregivers

Multiple-family groups should be used when caregivers of two or more beneficiaries with similar diagnoses and needs are present

Therapy services are not covered when there is no expectation of measurable functional improvement or continued clinical benefit. Specifically, services that are not necessary to maintain function or prevent deterioration — including therapy rendered only for maintenance without anticipated improvement — are excluded from coverage. This exclusion applies when the service does not reasonably offer medical benefit in improving the beneficiary’s ability to function.

Services that are primarily educational, vocational, recreational, duplicative of school-provided IFSP/IEP services, or custodial in nature are not medically necessary. Examples include interventions whose main purpose is education, treatments focused on vocational or recreational goals, or services that replicate an Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP) delivered outside the school setting. Custodial care is excluded when it is provided mainly to assist with activities of daily living (ADLs), to maintain safety, or when it could be performed by non‑professional caregivers.

Procedure Codes and Screening Thresholds

ABA procedure codes allowed via telehealth (listed)CPTCovered

97151	Assessment (documented in policy list) - allowed via telehealth
97152	Behavior identification supporting assessment - allowed via telehealth
97153	Adaptive behavior treatment by protocol - allowed via telehealth
97154	Group adaptive behavior treatment - allowed via telehealth
97155	Adaptive behavior treatment by protocol with technician - allowed via telehealth
97156	Family adaptive behavior treatment guidance - allowed via telehealth
97157	Multiple-family group adaptive behavior treatment guidance - allowed via telehealth
97158	Behavioral treatment plan development - allowed via telehealth

inv-07: MCHAT-R/F high-risk threshold — >= 8 (pediatrician may independently diagnose autism if clinical judgment concurs)

Threshold>= 8 on the M-CHAT-R/F

Clinical actionPediatrician may independently diagnose autism if clinical judgment concurs with a high-risk score (≥ 8)

DocumentationHigh-risk M-CHAT-R/F result should be included in the CDE and prior authorization materials

inv-08: MCHAT-R/F moderate-risk range — 3-7 (pediatrician may complete follow-up interview and may diagnose or refer based on clinical judgment)

RangeScore 3–7 on the M-CHAT-R/F

Clinical actionPediatrician may complete the M-CHAT-R/F follow-up interview

Authorization, Documentation, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization is required in two stages: (1) authorization to perform a comprehensive diagnostic evaluation (CDE), conduct a functional assessment, and develop a behavior treatment plan; and (2) a separate authorization to provide the ABA-based therapy services identified in the behavior treatment plan.

PA period shall not exceed 180 days
If member has primary coverage for ABA, MCO may accept primary insurer PA
First PA must be submitted by the ABA provider to conduct a functional assessment and develop a behavior treatment plan (Mental Health Services Plan Development by Non-Physician)
MCOs will not deny services solely based on age of the CDE; services will be denied if no CDE exists

Note

Providers must ensure the behavior treatment plan documents direct observation and describes observed behaviors, frequencies, settings, and supporting documentation. The plan must include a weekly schedule with expected hours per week, locations of service, intensity and frequency of requested therapy, justification for level of service, and supervision arrangements when technician services are used.

Outpatient, Home, and Community-Based ABA Services

ABA Clinical Entry and Workflow Criteria

ABA clinical entry criteria

ABA-specific criteria and workflow

Admission requirements for ABA: Services must be medically necessary, prior authorized by the MCO, delivered per the beneficiary's behavior treatment plan, and provided by or under supervision of a licensed behavior analyst, licensed psychologist, or licensed medical psychologist (payment billed by the licensed professional)

Prior to requesting ABA, a completed CDE by a QHCP is required

QHCP definitions and diagnostic scope: QHCPs include pediatricians (with MCHAT-R/F guidance), pediatric neurologists, developmental pediatricians, psychologists, psychiatrists, nurse practitioners under supervision, and licensed individuals (e.g., SLP, LCSW, LPC) who meet experience and supervision criteria; if supervised licensed individual performs CDE, QHCP must sign off

Pediatricians using MCHAT-R/F may independently diagnose autism with score >=8 if clinical judgment concurs; for scores 3-7 complete follow-up interview and either diagnose or refer based on clinical judgment

CDE components:

Family and Group Treatment Guidance

Family and multiple-family group adaptive behavior treatment guidance

Family adaptive behavior treatment guidance: Should be included in the behavior treatment plan for prior authorization to transfer skills to parent(s)/caregiver(s) and ensure consistency across environments; may be administered by a physician or other QHCP

Can be delivered individually or as multiple-family group when appropriate

Authorization Periods and Visit Limits

inv-19: Assessment and therapy authorizations — PA period shall not exceed 180 days

Maximum PA periodPrior authorization period shall not exceed 180 days

PA stagesPA is two-fold: (1) authorization to perform a functional assessment and develop a behavior treatment plan; (2) separate authorization to provide ABA-based therapy services

PA submissionPA request to conduct assessment and develop plan must include the CDE performed by a QHCP; CDE required in the first PA request per member per provider

Background and Rationale

Applied Behavior Analysis (ABA) services must be medically necessary and focused on measurable functional gains; services that are educational, duplicative of school services, vocational/recreational, or custodial are not appropriate uses of ABA under this policy. When evaluating ABA requests, reviewers should confirm that goals and interventions are clinical in nature and intended to produce observable improvement rather than substitute for educational or custodial supports.

Key Definitions

inv-14: Applied Behavior Analysis (ABA) — definition

DefinitionApplied Behavior Analysis (ABA) is the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce significant social improvement, including direct observation, measurement, and functional analysis of the relations between environment and behavior.

Therapeutic approachABA-based therapies teach skills through behavioral observation and reinforcement or prompting to teach each step of targeted behavior.

Evidence statusABA therapies are based on reliable evidence and are not experimental.

inv-15: Comprehensive Diagnostic Evaluation (CDE) — definition

DefinitionComprehensive Diagnostic Evaluation (CDE) — a diagnostic assessment that includes a thorough clinical history with the informed parent/caregiver; direct observation of the beneficiary; review of available records; a valid DSM-5 diagnosis; justification for referral or non-referral for an ABA functional assessment and possible ABA services; and recommendations for additional treatment, services, or evaluations.

Policy Summary

PayerOptum

PolicyLouisiana Medicaid Applied Behavior Analysis (ABA) - State-Specific Clinical Criteria

Policy CodePolicy BH803LA082025

Change TypeMaterial additions and clarifications

Effective DateJan 1, 2025

Last ReviewAug 19, 2025

Next Review DateAug 19, 2025

SourceLink

On This Page

Licensed professional should supervise no more than 24 technicians per day and no more than 10 CaBAs; one-on-one supervision may be conducted and billed concurrently with one-on-one therapeutic services when a non-licensed professional delivers therapy

Diagnosis or referralBased on clinical judgment after follow-up, pediatrician may either independently diagnose autism or refer to a listed subspecialist for diagnostic evaluation

Behavior treatment plan must be person-centered and include long-term, intermediate, and short-term behaviorally defined goals
Must identify outcome measurement criteria and the individual providers responsible for delivering services
Include parent/caregiver training, care coordination, and be consistent with ABA techniques
If provider uses own form it must include all elements from the LDH template (Appendix D)

Documentation Required

Required documentation for PA

Prior authorization requests for ABA-based therapy services must include the CDE, the behavior treatment plan, the individualized educational plan (IEP), and the waiver plan profile table and schedule from the certified plan of care when applicable.

The CDE must have been conducted by a qualified health care professional (QHCP); the CDE only needs to be included in the first PA request per member per provider
All CDEs completed by QHCPs will be reviewed and considered in PA decisions
MCOs are responsible for arranging CDEs if requested and will not deny or delay available ABA services solely while awaiting a CDE

Denial Risk

Triggers for denial

Requests will be denied when they lack a comprehensive diagnostic evaluation (CDE) or when services do not meet medical necessity (for example: primarily educational services, services duplicative of an IEP/IFSP, vocational/recreational treatment, custodial care, or when measurable functional improvement or continued clinical benefit is not expected).

Services without demonstrated medical necessity or those for maintenance without expected benefit are not covered
Services primarily educational in nature or duplicative of IDEA-mandated IEP/IFSP are not covered
Custodial care and services provided primarily for ADLs or safety that could be provided by non‑professionals are excluded

CDE must include a thorough clinical history, direct observation of current functioning (social, communication, play), review of records, DSM-5 diagnosis, justification for referral or non-referral to ABA, and recommendations for additional services or assessments; when screening is borderline, include autism-specific, general psychopathology, cognitive/developmental, and adaptive behavior assessments as appropriate

Who may performCDE must be performed by a Qualified Health Care Professional (QHCP); pediatricians using the M-CHAT-R/F may complete a CDE and diagnose in specified circumstances

When additional components neededWhen screening results are borderline or unclear, the CDE should include autism-specific assessments, general psychopathology assessments, cognitive/developmental assessment, and assessment of adaptive behavior specific to the beneficiary's age and cognitive abilities.