Premera Bluecross ABA Coverage Update

Coverage and Medical Necessity

Medical Necessity Criteria

Covered when ALL of the following are met

Diagnosis of Autism Spectrum Disorder (DSM-5/DSM-5-TR) or equivalent ICD-10 diagnoses (Autistic Disorder, Asperger's Syndrome, Pervasive Developmental Disorder Unspecified) made by a healthcare professional whose legally permitted scope of licensure includes diagnosis of psychiatric or neurodevelopmental disorders.

ABA is not medically necessary for other diagnoses.

Service types: Services consist of initial and periodic functional behavioral analyses, individual and group adaptive behavior treatment, family/caregiver education, training and coaching, and related components (case review, data analysis, treatment plan development and revision, treatment team conferences, real-time coordination/consultation).

Refer to the Coding section for mapped CPT/HCPCS codes and to BACB guidance for intensity recommendations.

Providers and supervision: Services are provided or supervised by specified qualified clinicians (e.g., BCBA/BCaBA, state-licensed behavior analysts (LBAs), licensed assistant behavior analysts (LaBAs) where allowed, licensed physicians, nurse practitioners, licensed psychologists, licensed mental health clinicians, occupational therapists, speech-language pathologists). Direct services delivered by behavioral technicians/therapy assistants/BCaBAs or Master's/Doctoral clinicians requiring supervision must be supervised by a program manager/lead behavioral therapist; supervision should include direct observation and may be provided in-person or via secure real-time telehealth/virtual modalities.

Supervisory activities (program development, treatment plan revision, data analysis, case review, and supervision) are covered only when performed by program managers/lead behavioral therapists.

Settings: Services are usually provided in home or clinic settings; community settings are acceptable when significant ASD-related difficulties occur there. A portion of direct treatment may occur in school only when the behavioral difficulties are evident and services delivered in the school consist entirely of bona-fide ABA treatment activities. Services may be delivered in-person, via secure real-time audio/video telehealth, or a combination.

Activities that are the responsibility of the school system or that are educational/recreational in nature are not covered.

Coverage and Not Medically Necessary Criteria

Covered when services are bona-fide ABA interventions delivered by covered ABA providers and meet medical necessity criteria; the policy specifies activities considered not medically necessary or non-covered.

Single-provider requirement: No more than one program manager/lead behavioral therapist for an identified individual at any one time or during the same episode of treatment; exception allowed only when a second provider group is providing a short-term, highly specialized, time-limited service substantially different from the primary provider's services.

Single direct clinician at a time: More than one clinician providing direct ABA treatment services to the same identified individual at the same time is considered unnecessary duplication and not medically necessary.

Concurrent non-ABA therapies: Concurrent provision of ABA and a different type of treatment (e.g., speech therapy, occupational therapy) to the same identified individual at the same time is considered not medically necessary because the individual cannot adequately focus on two different modalities simultaneously.

Group/session composition:

Settings and Modalities

Modalities and settings

Telehealth modalities: ABA services (direct treatment, supervision, and ancillary services such as treatment planning) may be provided via secure real-time audio and video telehealth/virtual modalities or a combination of in-person and telehealth modalities; literature and observational experience support non-inferiority in many contexts.

Telehealth may require increased parent/caregiver teaching and coaching during sessions.

School and camp exclusions: School programs, specialized school tuition, camps, and recreational programs are non-covered because they are educational or recreational and not covered facility types; only direct ABA treatment activities in the school setting that are entirely bona-fide ABA delivered by covered ABA providers may be covered.

Significant portions of school or camp programs are typically educational or recreational and therefore excluded unless otherwise directed by specific health plan stipulations.

Assessments and related activities performed by behavioral technicians, therapy assistants, paraprofessionals, or Board-Certified assistant behavior analysts that are outside their legally permitted scope of licensure are not covered (excluded). Documentation should demonstrate that any assessment billed corresponds to the provider type and scope permitted by state law and the policy coding section.

Direct ABA services delivered in school settings are covered only when they consist entirely of bona-fide ABA direct treatment activities provided by covered ABA providers. Services in schools that function as classroom aides, 1:1 teachers, or that otherwise constitute duties and responsibilities of the school district are not ABA services and are not medically necessary under this benefit.

Program development, treatment plan development/revision, data analysis, case review, and supervision are covered only when performed by a program manager/lead behavioral therapist; these administrative/supervisory functions are not separately covered when performed by technicians or assistants outside their permitted scope.

School programs and specialized school tuition for individuals with Autism Spectrum Disorder are non-covered because schools and educational programs are not covered facility types; services that are the responsibility of school districts should be provided by school staff unless a specific plan stipulation indicates otherwise.

Camps, camp programs, summer camps, and similar recreational programs are non-covered activities even if targeted to individuals with Autism Spectrum Disorder, because these programs are primarily recreational rather than ongoing, individualized ABA treatment.

Non-treatment items and activities are not covered, including provider travel time, transporting parents or other family members, babysitting, respite, and other services listed in the policy that are not behavioral assessment or treatment components.

Applied Behavior Analysis is considered medically necessary only for a diagnosis of Autism Spectrum Disorder (DSM-5/DSM-5-TR or equivalent ICD-10 diagnoses). ABA for diagnoses or conditions other than Autism Spectrum Disorder is not medically necessary.

The provision of ABA concurrently with a different type of treatment modality (for example, ABA and speech therapy or ABA and occupational therapy delivered to the same individual at the same time) is considered not medically necessary because the individual cannot adequately focus on and engage in two different treatment modalities simultaneously.

More than one program manager/lead behavioral therapist providing ABA for the same identified individual at the same time or during the same episode of treatment is considered unnecessary duplication and not medically necessary, except when a second provider group is providing a short-term, highly specialized service that is substantially different from the primary provider's services and not typically available from the primary provider.

More than one clinician providing direct ABA treatment to the same individual at the same time, or multiple agencies providing overlapping ABA services for the same episode of care, is not medically necessary. With the exception of bona-fide group treatment sessions or family therapy/collateral sessions focused on one identified individual, delivering direct ABA to more than one identified individual in the same session is also considered not medically necessary.

Billing Codes and Code Lists

Covered CPT CodesCPTCovered

0362T	Behavior identification supporting assessment; each 15 minutes of technicians' time face-to-face with a patient; requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
0373T	Adaptive behavior treatment protocol with modification, each 15 minutes of technician's time face-to-face with a patient; requiring the following components: Administration by the physician or other qualified health care professional who is on site; With the assistance of two or more technicians; For a patient who exhibits destructive behavior; Completion in an environment that is customized to the patient's behavior (0373T is reported based on a single technician's face-to-face time with the patient and not the combined time of multiple technicians ).
97151	Behavior identification assessment; administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non- face-to-face analyzing past data, scoring/interpreting the assessment; and preparing the report/treatment plan.
97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient; each 15 minutes.
97154	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes.
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient; each 15 minutes.
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.

Covered HCPCS / S CodesHCPCSCovered

H0031	Mental health assessment Used for initial evaluation/assessment; initial functional analysis, and periodic functional analysis re-assessments (must be done by a program manager/lead behavioral therapist).
H0032	Mental health service plan development Used for program development; treatment plan development or revision, data analysis, case review, treatment team conferences; supervision of therapy assistants/paraprofessionals, and for real-time direct communication/coordination with other providers (must be done by a program manager/lead behavioral therapist).
H2014	Skills training and development; per 15 minutes Used for direct services to member and/or parents (including parent education and training) by therapy assistants/behavioral technicians/paraprofessionals.
H2019	Therapeutic behavioral services, per 15 minutes Used for direct services to member and/or parents (including parent education and training) by program managers/lead behavioral therapists.
S5108	Home care training to home care client Used for direct services to member by therapy assistants/behavioral technicians/paraprofessionals.
S5109	Home care training to home care client Used for direct services to member by therapy assistants/behavioral technicians/paraprofessionals.
S5110	Home care training; family Used for direct services to parents and/or family (including parent education and training) by therapy assistants/behavioral technicians/paraprofessionals.
S5111	Home care training; family Used for

Historical / referenced CPT/HCPCS codesmixed

S5108	Added in history (reference to coding additions)
S5109	Added in history (reference to coding additions)
S5110	Added in history (reference to coding additions)
S5111	Added in history (reference to coding additions)
0362T	Added previously to coding (history notes)
0363T	Added previously to coding (history notes) and later removed as terminated 1/1/19

Provider Responsibilities and Billing Requirements

Billing Rule

Billing code requirement

Services must be billed using the specific CPT/HCPCS codes listed in the Coding section. In‑network providers of ABA must use those codes to be reimbursed; services not listed in the Coding section are not medically necessary covered services for ABA unless a specific health plan stipulation states otherwise.

Use the codes listed in the Coding section for reimbursement.
Services not listed in the Coding section are not covered for ABA unless the member contract or plan stipulations allow.

Denial Risk

ABA diagnosis limitation — Not medically necessary for other diagnoses

Applied Behavior Analysis (ABA) is considered not medically necessary for diagnoses other than Autism Spectrum Disorder. ABA is covered only when the diagnosis meets the policy’s Autism Spectrum Disorder criteria (DSM/DSM‑5‑TR or equivalent ICD‑10 diagnoses) and is made by a qualified clinician within their licensure scope.

Service Settings and Level-of-Care Rules

Outpatient / community-based ABA

Admission to ABA services: Demonstrated need related to Autism Spectrum Disorder and behaviors amenable to ABA interventions; diagnosis by a qualified provider and establishment of individualized treatment goals based on a functional behavioral assessment are required.

Refer to coding and provider sections for specific covered service codes and provider types.

Continued services: Ongoing documented progress toward treatment goals, periodic reassessment with functional behavioral analyses (generally every 6 to 12 months), and medically necessary supervision and program adjustments are required to support continued outpatient/community-based ABA.

Documentation should demonstrate progress and justify continued intensity of services; avoid duplicated services by multiple providers.

Outpatient

Admission:

Applied Behavior Analysis Specific Clinical Rules

ABA-specific clinical criteria

ABA is covered when delivered according to the service, provider, setting, and supervision rules detailed in the policy.

Service delivery per code definitions: Covered ABA services align with listed CPT and HCPCS/S codes for functional behavioral analysis, adaptive behavior treatment (individual, group, technician-delivered, and professional modification), family guidance, and program development/service plan activities.

In-network providers must bill using the listed codes to be reimbursed; see Coding section for exact mappings.

Supervision and observation: When direct services are provided by technicians/BCaBAs or clinicians requiring supervision, supervision must be by the ABA program manager/lead behavioral therapist and include some direct observation; supervision may be provided in-person or via secure telehealth.

Supervisory and program development activities are covered only when performed by program managers/lead behavioral therapists.

Provider scope: Assessments and services must be within the legally permitted scope of the delivering clinician; assessments by behavioral technicians/assistants are non-covered when outside their permitted scope.

Modalities of ABA Treatment

Behavioral therapy (ABA)

Modality allowance: Behavioral therapy (ABA) may be provided in-person or via secure real-time video/audio telehealth/virtual modalities; supervision and ancillary services may also use telehealth.

Providers must bill services using the codes listed in the Coding section and follow scope-of-practice rules.

Telehealth / Virtual ABA

Telehealth/virtual ABA (secure real-time audio and video) is allowed for direct treatment, supervision, and ancillary services; literature from the COVID-19 era supports non-inferior outcomes for virtual modalities in many contexts.

Telehealth sessions may involve increased caregiver coaching and should be documented accordingly.

Visit Limits and Treatment Hours

Policy notes — usual number of hours mentioned but no numeric visit limits specified in this portion of the document

Usual hours mentionedIntroduction and history note the policy discusses the 'usual number of hours covered' for ABA evaluation and therapy in the Introduction but this section does not specify numeric visit limits.

No numeric visit limits hereThe policy introduction and benefit sections reference usual hours but do not define specific daily or weekly visit limits in this portion of the document.

Refer to plan or full policy for limitsWhen numeric daily/weekly hour limits are needed, refer to specific health plan stipulations or other sections of the full policy where maximum medically necessary hours are defined.

ABA treatment hours — Maximum medically necessary daily/weekly ABA hours applies only to treatment hours; specific hour guidance

Scope of hour limitsClarified that the maximum number of medically necessary daily and weekly ABA hours applies only to treatment hours and does not apply to non-treatment ABA components (e.g., case review, supervision, program development).

Definitions and Provider Types

ABA — definition of Applied Behavior Analysis

DefinitionApplied Behavior Analysis (ABA): techniques applying learning principles focused on antecedents and consequences to change behavior, used to increase language, communication, social skills, attention, and adaptive behaviors in individuals with autism.

Service componentsABA services include behavioral assessments, individualized treatment, parent/caregiver training/coaching, supervision, program development, data analysis, and treatment plan revisions.

Clinical goalPrimary goal is to increase desired behaviors and decrease undesired behaviors through structured, data-driven interventions.

Functional behavioral analysis — definition and role

DefinitionFunctional behavioral analysis (assessment): an evaluation to identify the function of behaviors and to develop treatment plans; listed as initial and periodic services and mapped to specific codes (e.g., 97151, H0031).

Background

Applied Behavior Analysis (ABA) applies behavioral principles of antecedents and consequences to increase desired behaviors and decrease undesired behaviors. ABA is commonly used for individuals with Autism Spectrum Disorder to improve communication, social skills, attention, and adaptive functioning.

Covered ABA services include initial and periodic functional behavioral analyses, individualized treatment (one-on-one or bona-fide group), parent/caregiver education, supervision by a program manager/lead behavioral therapist, program development, data-based treatment planning and revisions, and coordination with other providers. Services may be provided in-person, via secure real-time audio/video telehealth, or a combination of modalities.

Providers must meet the policy's qualification requirements (e.g., program managers/lead behavioral therapists such as BCBAs or state-licensed behavior analysts where applicable); direct treatment may be provided by supervised behavioral technicians or assistants within their legally permitted scope and under required supervision that includes direct observation.

Applied Behavior Analysis (ABA) Coverage Criteria

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