ModifiedSelectHealthPolicy 630

Applied Behavior Analysis (ABA)

Defines medical necessity, documentation, intensity, continuation, and discontinuation criteria for ABA therapy for members with Autism Spectrum Disorder (ASD) under SelectHealth plans; includes state-specific diagnostic requirements and billing/unit guidance.

Policy Summary

PayerSelectHealth

PolicyApplied Behavior Analysis (ABA)

Policy CodePolicy 630

Change TypeCriteria and exclusions revised

Effective DateMar 14, 2019

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization before providing ABA services.

SourceLink

POLICY UPDATE CHANGES

For Commercial Plan Policy, comprehensively updated criteria for coverage and included language regarding exceptions for members on FEHB plans (7/1/25).

For Commercial Plan Policy, added clarifying language to criterion #4a: 'Documented failure, and prescribed by treating psychiatrist or psychiatric advanced practice registered nurse, of at least 2 antidepressant courses of maximally tolerated labeled dose and duration (> 4 weeks)'

Modified requirements in criteria #1 to #4 and added #5 in section A-I to align with updated clinical standards.

Added exclusion: Select Health does NOT cover TMS for ages 17 and under; considered experimental/investigational for this age group.

Added exclusion: Select Health does not cover TMS for migraine headaches (e.g., SpringTMS); considered experimental/investigational.

Changed age requirement from 'Patient is ≥ 18 years of age' (partial record of change present).

Modified scores in Ambulatory Detoxification criteria section for CIWA (16 or above) or COWS (36 or greater) which would prompt seeking treatment at a higher level of care.

2019-03-14Implementation

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.

2026-01-01Last review

32Assessment units (example)

18 & 24-30 moASD screening ages

20+ hrs/wkIntensive ABA

Coverage Criteria and Medical Necessity

Initial ABA Medical Necessity Criteria

Covered when ALL of the following are met:

Diagnosis: DSM-V diagnosis of Autism Spectrum Disorder (ICD-10: F84.0; F84.3-F84.9) obtained by an appropriately licensed provider according to state requirements.

Recommendation/Prescriber: ABA is recommended or prescribed by a qualified treating healthcare professional experienced in diagnosis and treatment of ASD as defined by state law.

See state-specific provider qualifications.

Essential Elements (treatment plan & targets): Identifiable target behaviors significantly impair participation in developmentally appropriate activities or pose risk; an individualized treatment plan with baseline objective measures, quantifiable progress and mastery criteria, specified behavioral intervention techniques, identified reinforcers, transition/fading/discharge criteria, staff identified, start date, and caregiver training plan is documented.

Functional analysis, focused, or comprehensive assessment unit examples provided; ABA not custodial.

Provider qualifications & supervision: Services are provided directly or supervised by licensed behavior analysts, board-certified behavior analysts, or licensed psychologists where within scope; supervision is at least 5% of direct service hours and at least monthly unless state/contract requires otherwise.

If unlicensed/non-certified providers are authorized per state/contract, supervision and direction must meet practice standards.

Intensity justification: Requested units and intensity of service reflect severity of impairments and treatment goals (assessment and treatment units consistent with Functional Analysis, Focused, or Comprehensive examples).

See billing/coding guide for assessment unit examples (Functional Analysis 8-16 units; Focused 16-24 units; Comprehensive 32 units).

Continuation Criteria

Continuation covered when ALL of the following are met:

Ongoing Essential Elements: The Essential Elements of the treatment plan continue to be met.

Authorization review: Continued authorization is adjusted based on clinical review of medical necessity including intensity and severity; reviews occur up to every 6 months.

Progress or Modification: Either (A) documented improvement in frequency of target behaviors with planned gradual tapering and shift to other supports, OR (B) if progress is insufficient, documented treatment modification with additional assessments and expert consultations.

Use validated scales for review (e.g., VABS-3, ABAS, VB-MAPP, ABLLS).

Caregiver involvement: Caregivers continue education and training to implement strategies and support generalization of skills.

Discontinuation / Not Medically Necessary

Services considered not medically necessary when ANY of the following apply:

Discontinuation / Not medically necessary: Essential Elements are no longer met; parent/family/caregiver/guardian have not participated in treatment for successive authorization periods; or the member has achieved treatment goals or has not demonstrated progress for successive authorization periods.

Triggers denial of continued services.

Medical necessity for ASD

Covered when services meet medical necessity criteria for ASD and are used to address functional impairments per guidelines.

General coverage stance for ASD: ABA is considered medically necessary for individuals with Autism Spectrum Disorder when the medical necessity criteria are met; ABA is considered experimental/investigational and not covered for indications other than ASD.

Supported by CASP/BACB guidance and research summaries; intensive early intervention (>20 hours/week) may yield larger gains in some studies.

Discontinuation of services

Discontinuation/continued-service criteria

Discontinue/Not medically necessary when ANY of the following are met: a) Essential Elements are no longer met; b) Parent/Family/Caregiver/Guardian have not participated in treatment for successive authorization periods; c) The member has achieved treatment goals or has not demonstrated progress for successive authorization periods.

These conditions trigger denial of continued services.

Chemical Aversion Therapy — Commercial/CHIP Coverage

Covered when part of a coordinated treatment plan:

Commercial/CHIP coverage: Chemical aversion therapy is covered for the treatment of alcoholism and similar substance use disorders when delivered as part of a coordinated treatment plan that includes therapy and support.

When chemical agents (e.g., emetine, apomorphine, lithium) are used, patients require medical observation because these agents are not FDA-approved specifically for aversion therapy.

EMDR - Covered Indication

Covered when ALL of the following are met

EMDR coverage—PTSD only: Select Health covers EMDR only for post-traumatic stress disorder (PTSD) when the member's benefit plan provides coverage for outpatient psychotherapy and clinical documentation supports the diagnosis and treatment.

Coverage is limited to PTSD; verify member benefits and applicable program (Medicare/Medicaid) rules.

EMDR - Not Covered Indications

Not covered (considered experimental/investigational) when ANY of the following apply

EMDR non-PTSD indications: Prevention of PTSD; chronic phantom limb pain; panic and anxiety disorders (other than PTSD); and other psychiatric/behavioral disorders (e.g., anger, depression, dissociative disorders, eating disorders, guilt, phobias).

Effectiveness for indications other than PTSD has not been established and such uses are considered experimental/investigational.

EMDR Evidence

EMDR — evidence summary and coverage context

EMDR evidence summary: Evidence consists primarily of pilot studies, small case reports, and limited trials showing symptom reduction in trauma-related conditions (e.g., postnatal PTSD, case reports in adolescent depression); authors consistently state that further well-designed studies are needed.

EMDR is empirically validated for trauma-related disorders; evidence for other indications is insufficient.

Hippotherapy Coverage

Hippotherapy coverage determination

Commercial coverage stance: Select Health does NOT cover hippotherapy (equine movement therapy/equine-facilitated psychotherapy) as a rehabilitative or psychological therapy; it is considered experimental/investigational.

Evidence consists mainly of small case series and a few small trials; implementation guidelines are lacking.

Not Covered / Investigational

Coverage stance

Not covered / investigational interventions: Hippotherapy and Mickel Therapy are considered investigational/experimental/unproven for the indications described and are not covered; select health specifically does not cover Mickel Therapy for fibromyalgia.

Health and behavior CPT codes listed related to these services are labeled Not covered for these indications.

TMS coverage — initial and retreatment criteria

Select Health covers unilateral or bilateral repetitive TMS in patients with treatment-resistant depression when either A or B are met:

Approval pathways: A. Recommended by Intermountain Health Psychiatry Group; OR B. For other clinicians, ALL core coverage criteria below must be met.

Core coverage criteria for non-Intermountain referrals: 1) Patient >= 15 years of age; 2) DSM-5 diagnosis of major depressive disorder by a licensed mental health professional; 3) TMS recommended by a psychiatrist or psychiatric APRN after face-to-face exam and monitoring by a physician/APP responsible for motor threshold and response; 4) Failure of medication therapy per defined medication-failure criteria (see Medication failure criteria); 5) Adequate trial of evidence-based psychotherapy (typically >=15 sessions over 4–6 months) without documented significant improvement; 6) A TMS treatment plan of 36 treatments over a 10-week period; 7) Retreatment only if initiation criteria met and prior response/relapse documentation present (repeat within 60 days not medically necessary).

Motor threshold re-determination and retreatment limitations apply.

Medication failure criteria

Medication failure definitions (mutually exclusive branches depending on course chronicity)

4A New onset/non-recurrent depression: For new onset/non-recurrent moderate-to-severe depression (initial diagnosis within past 24 months): documented failure of at least 4 antidepressant courses of maximally tolerated dosage and duration (>4 weeks) from at least 2 different agent classes within the past 24 months OR demonstrated intolerance to >=4 courses from >=2 classes within past 24 months.4 courses / 24 months

Failure must be prescribed and documented by treating clinician.

4B Chronic/recurrent depressive disorder: For chronic/recurrent depression (treated >=24 months): documented failure of at least 2 antidepressant courses of maximally tolerated dosage and duration (>4 weeks) from at least 2 different agent classes within the past 12 months OR demonstrated intolerance to >=2 courses from >=2 classes within past 12 months.2 courses / 12 months

Applies to chronic/recurrent cases.

Contraindications and exclusions

Contraindications and non-covered indications

Contraindications: Substance abuse in past 90 days; high suicide risk requiring hospitalization; metal implant in/around the head (e.g., aneurysm clip/coil, metal plate, ocular implant, stent); neurological conditions (cerebrovascular disease, dementia, severe/repetitive head trauma, increased intracranial pressure, CNS tumors); implanted magnetically-sensitive devices <=30 cm from coil (cochlear implant, ICD, pacemaker, VNS, aneurysm clips/coils, staples, stents); severe cardiovascular disease unless cleared by cardiologist.

Dental amalgam fillings acceptable.

Non-covered TMS indications: Unilateral rTMS and bilateral rTMS for behavioral health indications other than MDD are considered experimental/unproven and not covered; TMS for migraine headaches and TMS as maintenance therapy to prevent relapse are not covered.

Medicare/Medicaid may follow CMS or state policies.

nTMS — coverage for motor and language mapping

nTMS coverage for motor and language mapping

nTMS motor mapping: Covered for motor mapping when age > 1 year (equipment limitations may restrict younger ages).age > 1

nTMS language mapping: Covered for language mapping when age > 12 years (assuming normal neurodevelopmental status).age > 12

Pediatric nTMS indications: When a child, nTMS is covered only for (a) supratentorial tumor targeted for resection that may encroach on motor/language cortex, or (b) drug-resistant epilepsy requiring presurgical mapping at an NAEC Level 4 comprehensive epilepsy program.

Surgical intervention includes curative or palliative procedures (e.g., DBS, RNS).

General Coverage Criteria

Covered for indications when clinical criteria are met (policy references treatment-resistant depression and navigated mapping indications).

General clinical coverage logic: Coverage is contingent on meeting indication-specific clinical criteria (e.g., TMS for treatment-resistant MDD per medication/trial and age criteria; nTMS for mapping per age and surgical indication).

Evidence supports rTMS for treatment-resistant MDD; dTMS evidence limited; comparative effectiveness vs ECT is mixed.

Not covered (Commercial & CHIP)

Select Health Commercial and CHIP policy

Not covered—UROD: Select Health does NOT cover ultra-rapid opioid detoxification (UROD) / anesthesia-assisted opioid antagonist detoxification for treatment of opioid dependence; considered experimental/investigational for Commercial and CHIP plans.

Serious safety concerns and insufficient controlled evidence noted.

Public program application

Medicare and Medicaid applicability

Medicare application: Medicare coverage is determined by CMS; if CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies.

Refer to CMS resources for current determinations.

Medicaid application: Select Health Community Care (Medicaid) policies typically align with State of Utah Medicaid policy and may use InterQual; situations may use NCD/LCD or commercial policy as applicable.

Refer to state Medicaid resources for details.

Coverage criteria for Withdrawal Management

Covered when ALL of the following are met

Benefit & criteria alignment: Member has appropriate benefit coverage at time of request; inpatient withdrawal management meets InterQual criteria and outpatient withdrawal management meets ASAM criteria.

Coverage contingent on member benefits and level-of-care criteria.

Facility/provider capability: Facility/provider is equipped to provide the requested level of care with 24-hour access to medical evaluation/consultation, credentialed personnel, and safe staffing.

Includes ability to monitor withdrawal and implement physician-approved protocols.

Intensity of service requirements: Services must include evidence of drug screens and relevant labs at admission, a multidisciplinary individualized treatment plan developed within 24 hours, access to psychiatric/psychological/supportive services, and consideration of MAT unless contraindicated.

Elements required for certification of level of care throughout treatment.

Initial and Intensity Criteria for Ambulatory Detoxification

Covered when ALL of the following are met for Ambulatory Detoxification

Ambulatory Detoxification Initial Criteria: 1) DSM diagnosis of a substance use disorder with withdrawal as the primary focus; 2) Treatment is not primarily social/custodial; 3) Documentation of current substances used (substance, duration, frequency, last use, quantity) and urine drug monitoring/breathalyzer; 4) At least three documented signs/symptoms of active moderate withdrawal or expectation within 48 hours, or historical pattern requiring 24-hour medical/nursing intervention; 5) Member expresses commitment to ongoing care; 6) Member has sufficient coping skills and motivation for outpatient detoxification; 7) Supportive environment or skills to cope; 8) Services provided by medical personnel who can monitor withdrawal and implement physician-approved protocols; 9) Evidence of drug screens and relevant labs at admission and as indicated; 10) 24-hour access to qualified provider evaluation/consultation; 11) Access to psychiatric/psychological/supportive services; 12) Individualized treatment plan within 24 hours; 13) Consideration of MAT unless contraindicated; 14) Services delivered face-to-face in regularly scheduled outpatient sessions; 15) Contact with recent treating providers within 3 days; 16) Family/support coordination evidenced by contact with family.

Use validated scales (CIWA/COWS) for monitoring and escalation.

Continuation and Exclusion Criteria

Continuation criteria: Ambulatory detoxification is intended for up to 5 to 7 days; continuation beyond 7 days requires prior authorization with documentation and specific treatment goals.

Exclusions for ambulatory detoxification: Patients with severe and repeated substance abuse; psychiatric comorbidity preventing cooperation; severe, complicated medical comorbidities (e.g., history of seizures, poorly controlled BP, uncontrolled cardiopulmonary conditions); presence of life‑threatening conditions; or acceleration of symptoms creating an unstable situation requiring inpatient care are excluded from ambulatory detoxification.

These conditions render ambulatory detoxification inappropriate.

Ambulatory Detoxification — Escalation

Criteria prompting seeking treatment at a higher level of care in Ambulatory Detoxification:

Escalation triggers: CIWA score of 16 or above OR COWS score of 36 or greater prompts seeking treatment at a higher level of care.CIWA >=16; COWS >=36

Revision to thresholds in Commercial Plan Policy.

Select Health considers Applied Behavior Analysis (ABA) therapy experimental/investigational for all indications other than Autism Spectrum Disorder (ASD) because the policy indicates a lack of clinical literature demonstrating efficacy for non‑ASD uses.

ABA therapy is not covered for indications other than ASD; the policy classifies such uses as experimental/investigational due to insufficient evidence supporting efficacy outside of ASD.

Chemical aversion therapy uses agents such as emetine, apomorphine, and lithium to induce unpleasant symptoms paired with substance exposure; none of these agents are FDA‑approved specifically for aversion therapy, and the policy notes that patients treated with these drugs should be kept under medical observation when used in this context.

Select Health covers EMDR only for post‑traumatic stress disorder (PTSD). Use of EMDR for prevention of PTSD or for other conditions (for example, chronic phantom limb pain, panic and anxiety disorders other than PTSD, depression, eating disorders, phobias, dissociative disorders, guilt, or anger) is considered experimental/investigational and is not covered.

Select Health lists multiple therapies and specific service codes as not covered when the interventions are investigational/experimental or lack sufficient evidence. Examples include numerous indications summarized as “not covered for indications listed,” hippotherapy and related health and behavior codes (listed as investigational), and other interventions designated as unproven.

Select Health does NOT cover Mickel Therapy for the treatment of fibromyalgia; the policy classifies this therapy as experimental/investigational for that indication.

Hippotherapy (equine movement therapy / equine‑facilitated psychotherapy) and associated codes (for example, HCPCS S8940 and health and behavior CPT codes listed) are labeled Not covered — Investigational/Experimental/Unproven for the indicated uses.

Select Health does NOT cover repetitive TMS (rTMS) for behavioral health indications other than major depressive disorder (MDD). Unilateral rTMS for any behavioral health indication other than MDD is considered experimental/investigational; bilateral rTMS for behavioral health indications other than MDD is considered unproven.

For commercial members, TMS coverage requires meeting the policy criteria (including documented medication and psychotherapy trials) and the policy excludes TMS for ages 17 and under. The policy also states that TMS for migraine headaches (e.g., SpringTMS) is not covered as investigational.

Select Health does not cover ultra‑rapid opioid detoxification (UROD) for the treatment of opioid dependence; this procedure is classified as experimental/investigational for Commercial and CHIP plans.

If a patient’s severity is present only in ASAM Dimensions 4, 5, and/or 6 without high severity in Dimensions 1, 2, or 3, then the patient does not qualify for higher levels of care (e.g., Level 4); the policy uses ASAM dimensional scoring to determine appropriate level placement.

Examples of severe comorbidities or situations that make ambulatory detoxification inappropriate include: severe and repeated substance abuse; psychiatric comorbidity that prevents cooperation; severe, complicated medical comorbidities (for example, history of seizures, poorly controlled blood pressure, uncontrolled cardiopulmonary disease); presence of life‑threatening conditions; or accelerating symptoms that require inpatient care.

The policy’s lists of procedure and diagnosis codes are informational only. Inclusion or exclusion of a code in this policy does not by itself guarantee member coverage or provider reimbursement; benefits and eligibility are determined by the member’s individual benefit plan in effect at the time of service.

Continued ABA services are considered not medically necessary when the policy’s Essential Elements are no longer met. This includes cases where the individualized treatment plan no longer identifies appropriate target behaviors, objective progress criteria are absent, or other core elements required for medical necessity are missing.

The policy states that continued services may be denied if caregivers fail to participate across successive authorization periods; caregiver engagement and training are required components for ongoing authorizations.

Coverage decisions and code applicability depend on the member’s benefit plan and eligibility at the time of service. The policy does not itself guarantee coverage; providers and members must verify benefits and prior authorization requirements with Select Health or consult the member contract for determinations.

Billing Codes and Coding Guidance

ASD diagnosis codes referencedICD-10

F84.0	Autism spectrum disorder
F84.3-F84.9	Other pervasive developmental disorders / ASD-related codes as listed

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 with protocol modification, 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.
96202	Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes.
96203	Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); each additional 15 minutes (List separately in addition to code for primary service).
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.
97152	Behavior identification-supporting assessment, administered by one technician under the direction

Covered CPT Codes (partial list)CPTCovered

0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time
96202	Multiple-family group behavior management/modification training; initial 60 minutes
96203	Multiple-family group behavior management/modification training; each additional 15 minutes
97151	Behavior identification assessment, each 15 minutes of practitioner's time
97152	Behavior identification-supporting assessment, technician, each 15 minutes

Covered CPT Codes (continued)CPTCovered

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 professionals, 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.
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professionals (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professionals, face-to-face with multiple patients, each 15 minutes

CPT CODESCPT

90899

Unlisted psychiatric service or procedure

HCPCS CODESHCPCS

No codes listed

Nonspecific CPT/HCPCS codes used to bill for EMDRmixed

90785	Interactive complexity (List separately in addition to the code for primary procedure)
90832	Psychotherapy, 30 minutes with patient and/or family member
90833	Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834	Psychotherapy, 45 minutes with patient and/or family member
90836	Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837	Psychotherapy, 60 minutes with patient and/or family member
90838	Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90880	Hypnotherapy
90899	Unlisted psychiatric service or procedure
H0004	Behavioral health counseling and therapy, per 15 minutes

HCPCS / HippotherapyHCPCSNot Covered

S8940

Equestrian/hippotherapy, per session

CPT Health and Behavior codes listed as Not coveredCPTNot Covered

96150	Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96151	Health and behavior assessment, re-assessment, each 15 minutes face-to-face with the patient; re-assessment
96152	Health and behavior intervention, each 15 minutes, face-to-face; individual
96154	Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)

CPT / HCPCS unspecifiedmixed

No codes listed

Covered CPT Codes (when criteria met)CPTCovered

90867	Therapeutic repetitive transcranial magnetic stimulation treatment planning
90868	TMS delivery and management, per session
90869	Subsequent motor threshold re-determination with delivery and management

HCPCS CodesHCPCS

No codes listed

Not Covered: Investigational/Experimental/Unproven for this indicationmixedNot Covered

01999	Unlisted anesthesia procedure(s)
H0009	Alcohol and/or drug services; acute detoxification (hospital inpatient)
J2310	Naloxone injection, per 1 mg

Listed CPT CodesCPT

01999	Unlisted anesthesia procedure(s)
H0009	Alcohol and/or drug services; acute detoxification (hospital inpatient)

Listed HCPCS CodesHCPCS

J2310

Naloxone injection, per 1 mg

CPT CodesCPT

No codes listed

Covered HCPCS CodesHCPCSCovered

H0001	Alcohol and/or drug assessment
H0002	Behavioral health screening to determine eligibility for admission to treatment program
H0003	Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs
H0004	Behavioral health counseling and therapy, per 15 minutes
H0005	Alcohol and/or drug services; group counseling by a clinician
H0006	Alcohol and/or drug services; case management
H0007	Alcohol and/or drug services; crisis intervention (outpatient)
H0008	Alcohol and/or drug services; subacute detoxification (hospital inpatient)
H0009	Alcohol and/or drug services; acute detoxification (hospital inpatient)
H0010	Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient)

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Not Covered HCPCS CodesHCPCSNot Covered

H0019	Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem
H0021	Alcohol and/or drug training service (for staff and personnel not employed by providers)
H0023	Behavioral health outreach service (planned approach to reach a targeted population)
H0022	Alcohol and/or drug intervention service (planned facilitation)
H0024	Behavioral health prevention information dissemination service (one-way direct or nondirect contact with service audiences to affect knowledge and attitude)
H0025	Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior)
H0034	Medication training and support, per 15 minutes
H0037	Community psychiatric supportive treatment program, per diem
H0036	Community psychiatric supportive treatment, face-to-face, per 15 minutes
H0048	Alcohol and/or other drug testing: collection and handling only, specimens other than blood

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Informational codes disclaimermixed

No codes listed

Intensity of treatment by domain — examples of hours/week by severity

Mild (example)Approximately 0.1–4 hours per week per affected domain (e.g., maladaptive behavior, social communication, self‑care)

Moderate (example)Approximately 0.4–7 hours per week per affected domain

Severe (example)Approximately 0.7–10 hours per week per affected domain

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Authorization units and intensity

Authorization units and intensity should be guided by the documented assessment type and the member's severity of impairment. Requested units and intensity must reflect severity, goals, and response to treatment across settings; charted hours are additive. Examples of assessment unit guides: Functional Analysis (8–16 units), Focused assessment/treatment (16–24 units), Comprehensive (32 units). Authorization for caregiver training and protocol modification may be provided (e.g., 1–2 hours per 10 hours of treatment) based on clinical recommendation.

Assessment-based authorization ranges: Functional Analysis 8–16 units; Focused 16–24 units; Comprehensive ~32 units
Caregiver training and protocol modification: authorized based on clinical need (example: 1–2 hours per 10 hours of treatment)

Prior Authorization

Prior authorization and continuation requirements

Prior authorization and continuation require initial demonstration that Essential Elements and medical necessity are met. Continued authorization is contingent on documented improvement or, if progress is lacking, documented reassessment, modification of the plan, and consultations. Continued authorization reviews should occur up to every 6 months and frequency/intensity should be adjusted based on clinical review.

Background and Scope

Autism Spectrum Disorder (ASD) is typically identified in early childhood and is a lifelong neurodevelopmental condition. Select Health’s ABA policy limits routine ABA coverage to members with a documented DSM‑5 diagnosis of ASD and requires individualized treatment plans with baseline objective measures, quantifiable progress and mastery criteria, identifiable target behaviors that impact functioning, and caregiver training and participation. ABA treatment intensity should align with documented severity across functional domains.

Definitions

ABA — Applied Behavior Analysis definition

DefinitionApplied Behavior Analysis (ABA): interventions based on principles of learning theory evaluated with reliable and objective measurement to improve socially important behavior.

IntentUsed to increase, maintain, generalize, restrict, or reduce behaviors important for functioning in individuals with ASD

PractitionersABA methods are delivered by qualified behavior analysts or technicians under supervision as defined in policy sections

ASD — Autism Spectrum Disorder definition

DefinitionAutism Spectrum Disorder (ASD): a neurodevelopmental condition typically diagnosed in childhood with variable severity and combinations of symptoms; often lifelong.

Diagnosis codes

Level-of-Care Criteria and Service Settings

Outpatient/Behavioral Therapy (ABA) — level-of-care criteria nodes

Level-of-care and clinical operational criteria for outpatient ABA services and treatment components

Assessment: Initial comprehensive assessment with baseline objective measures for each target behavior and quantifiable criteria for progress and mastery.

Assessment unit examples: Functional Analysis 8-16 units; Focused 16-24 units; Comprehensive 32 units.

Treatment plan elements: Individualized member-centric treatment plan specifying strengths/needs, caregiver goals, reinforcers, techniques, staff, start date, transition/fading/discharge criteria, and plan for caregiver training and progress measurement.

Quantifiable criteria for progress and mastery required.

Service components & coding: ABA service components and CPT codes specify administration by qualified professionals, technician-delivered treatment, family guidance and group services; timed units are billed per 15 minutes.

Applied Behavior Analysis (ABA) Specific Criteria

Treatment Modalities

Authorization Units, Session Counts, and Visit Limits

ABA assessment/treatment units — Units mapped to assessment/treatment type (Functional Analysis, Focused, Comprehensive) with example ranges

Functional Analysis unitsFunctional Analysis (assessment type) example: 8–16 authorization units

Focused treatment unitsFocused treatment example: 16–24 authorization units

Comprehensive treatment unitsComprehensive program example: 32 authorization units

ABA CPT codes billed in 15-minute units (where specified)

Billing unit incrementABA CPT codes (e.g., 97151–97158, 0362T, 0373T) are billed in 15‑minute timed units where specified

Service componentsCodes describe technician vs clinician delivery, face‑to‑face time, and supervision requirements

Revision History and Policy Changes

2026-01-01policy_reviewLatest

Policy last reviewed on 2026-01-01 per document header dates.

2026-01-20criteria_revision

Commercial Plan Policy: changed TMS age requirement text (partial record) indicating modification to age eligibility wording.

2025-07-01comprehensive_update

Commercial Plan Policy: comprehensively updated coverage criteria and included language regarding exceptions for members on FEHB plans.

Policy Summary

PayerSelectHealth

PolicyApplied Behavior Analysis (ABA)

Policy CodePolicy 630

Change TypeCriteria and exclusions revised

Effective DateMar 14, 2019

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization before providing ABA services.

SourceLink

On This Page

nTMS contraindications/limits: No absolute contraindications identified; rare scenarios with cranial/intracranial hardware may be reviewed case-by-case.

Intensity associated with reported large gains — >20 hours/week

Reported intensive ABA frequency> 20 hours per week (intensity associated with large developmental gains in some studies)

ContextFindings refer to intensive, early intervention (often beginning before age 4) in research summaries

Evidence noteLarge gains reported in some studies but authors call for larger, well‑designed trials to confirm results

Timed unit — 15 minutes per unit

Timed billing unit15 minutes per unit for ABA CPT/assessment and treatment codes (e.g., 0362T, 0373T, 97151–97158)

Common applicationAssessment and technician/clinician face‑to‑face services are reported and billed in 15‑minute increments

Related codesAlso applies to multiple ABA service codes listed in the billing/coding section

Motor threshold re-determination frequency — No more than 3 re-determinations in a rolling 6-month period

Maximum re‑determinationsNo more than 3 motor threshold re‑determinations in a rolling 6‑month period (claims >3 will be denied)

Documentation requirementEach re‑determination must have medical record documentation justifying change in clinical status or regimen

Routine policyRoutine motor threshold re‑determination during rTMS therapy is not considered reasonable and necessary

Antidepressant treatment trials — at least 2 courses from different agent classes with specified durations

Chronic/recurrent depression requirementDocumented failure of at least 2 antidepressant courses (maximally tolerated dose/duration >4 weeks) from ≥2 different agent classes within the past 12 months for chronic/recurrent depressive disorder

New/non‑recurrent depression requirement(Per earlier commercial criteria) documented failure of at least 4 antidepressant courses from ≥2 classes within past 24 months for new/non‑recurrent cases

Prescriber and documentationFailures/intolerance should be documented and prescribed by the treating physician or psychiatric APRN as specified in revision notes

CIWA and COWS thresholds — CIWA >=16; COWS >=36 — consider transition to inpatient setting

Escalation thresholdsConsider transition to inpatient setting when CIWA ≥ 16 or COWS ≥ 36

CIWA contextCIWA referenced as prompting inpatient transition when score has escalated to 16 and above

COWS contextCOWS referenced as prompting inpatient transition when score has escalated to 36 or greater

Signs/symptoms threshold — At least three documented signs/symptoms of active moderate withdrawal or expectation within 48 hours

Required withdrawal signsAt least three documented signs/symptoms of active moderate withdrawal present or expected within 48 hours

Alternate criterionOr a historical pattern of withdrawal requiring 24‑hour medical/nursing intervention

Documentation elementsDocument substances used (type, duration, frequency, last use, quantity) and urine drug monitoring/breathalyzer at admission

CIWA score threshold — >= 16

CIWA score threshold>= 16 (CIWA score prompting consideration of higher level of care)

ReferenceCIWA escalation guidance cited in Withdrawal Management criteria and revision history

ApplicationUsed as a trigger during ambulatory detoxification to seek inpatient care

COWS score threshold — >= 36

COWS score threshold>= 36 (COWS score prompting consideration of higher level of care)

ReferenceCOWS escalation guidance cited in Withdrawal Management criteria and revision history

ApplicationUsed as a trigger during ambulatory detoxification to seek inpatient care

Initial authorization: document Essential Elements and individualized treatment plan with baseline measures
Continuation: must show improvement in target behavior or documented modification/assessments if progress is insufficient
Authorization review interval: up to every 6 consecutive months (adjust frequency/intensity as clinically indicated)

Note

Coverage determination and affected codes

Coverage determinations depend on the member's individual benefit plan and the applicable product (Commercial, Medicare, Medicaid). Inclusion of CPT/HCPCS codes in this policy is informational and does not guarantee coverage or reimbursement; always verify benefits and eligibility prior to service.

Coverage is determined by the member's benefit plan in effect at the time of service
Medicare coverage follows CMS determinations; if CMS has no determination and InterQual is not available, commercial policy may apply
Inclusion/exclusion of codes in this policy is informational only — verify benefits

Prior Authorization

Prior authorization required for TMS CPT codes

Prior authorization is required for Transcranial Magnetic Stimulation (TMS) CPT codes when clinical criteria are met. Providers must document applicable clinical criteria, prior medication trials, psychiatrist/APP recommendation and monitoring, and any motor threshold determinations.

Prior authorization required for CPT codes: 90867, 90868, 90869 when coverage criteria for TMS are satisfied
Document psychiatrist or psychiatric APRN recommendation after face-to-face exam and medication history

Denial Risk

Non-PTSD indications exclusion

Select Health considers Applied Behavior Analysis (ABA) and other therapies for specified indications only. ABA is covered only for Autism Spectrum Disorder (ASD) when Essential Elements are met; ABA for other indications is experimental/investigational and not covered. Non-PTSD indications for EMDR and other therapies are similarly considered investigational.

ABA coverage limited to ASD when Essential Elements and medical necessity criteria are met; ABA for other indications is experimental/investigational
EMDR covered only for PTSD; all other EMDR indications are considered experimental/investigational

Denial Risk

Hippotherapy coverage stance

Select Health does NOT cover hippotherapy (equine movement therapy) for rehabilitative or psychological therapy; it is considered experimental/investigational for the listed indications and will be denied.

Hippotherapy is Not covered: Investigational/Experimental/Unproven

Denial Risk

Not covered services — denial triggers

Not-covered services and denial triggers are identified for experimental/investigational or unproven interventions. Codes associated with such services are listed for information and will be denied when submitted for excluded indications.

Examples of not-covered codes for investigational/unproven services: 96150–96154 (health/behavior assessments/interventions) when used for investigational indications; S8940 as listed elsewhere
Inclusion of a code in this policy does not imply coverage — benefits must be verified

Denial Risk

Triggers for denial (commercial plan)

Commercial-plan denial triggers include failure to meet required step or medication-failure criteria, exceeding allowed re-determinations, lack of documented progress, or caregiver non-participation. Providers should be aware that exceeding frequency limits or missing required documentation may result in denial.

TMS: More than three motor threshold re-determinations in a rolling six-month period will be denied (commercial plans).
ABA/Treatment: Lack of documented progress or failure of caregivers to participate for successive authorization periods may trigger discontinuation.
Ambulatory detox: Treatment beyond 7 days requires preauthorization with documented goals; otherwise services may be denied.

Prior Authorization

Coverage contingent on benefit and criteria

Coverage for levels of care such as withdrawal management is contingent on meeting ASAM or InterQual criteria and the member's benefit coverage. Facilities must be capable of delivering the requested level of care; coverage decisions depend on both benefit and clinical criteria.

Outpatient WM requires ASAM criteria; inpatient WM requires InterQual criteria
Facility capability requirements include 24-hour access to medical evaluation, appropriate staffing, and ability to perform drug screens and labs

Billing Rule

Billing/Coding documentation

Billing and coding documentation must accurately reflect services rendered, include appropriate CPT/HCPCS codes, and be supported by the medical record and treatment plan. Inclusion of codes in this policy is informational only; verify coverage before billing.

Providers must document services with applicable CPT codes (see CPT coding block) and ensure claims include supporting documentation tied to the individualized treatment plan
Verify member benefits and eligibility prior to rendering and billing services

Billing Rule

CPT coding and documentation

Providers should use the listed CPT codes when billing ABA services and include supporting documentation. Key ABA and related CPT/HCPCS codes include assessment, treatment, and caregiver training codes; these are informational and do not guarantee coverage.

Key ABA CPT codes: 0362T, 0373T, 96202–96203, 97151–97158, 97152–97157
HCPCS/other codes (informational): H0004, 96150–96154 (note: some of these codes may be not covered for investigational uses)

Billing Rule

Billing and documentation notes

When billing for services such as EMDR, ABA, TMS, or withdrawal management, include the specific CPT/HCPCS codes and ensure documentation supports medical necessity and the billed level of service. Non-specific psychotherapy codes may be used where applicable, but benefits must be verified.

EMDR-related nonspecific CPT codes (informational): 90785, 90832–90838, 90880, 90899; HCPCS H0004 for behavioral health counseling
TMS CPT codes (informational/covered when criteria met): 90867, 90868, 90869

Documentation Required

Documentation and contact

Providers must consult the member's benefit plan and contact Select Health Provider Relations with questions. Verify benefits and eligibility at the time of service and prior to authorization requests.

Providers may contact Select Health Provider Relations at 801-442-3692 for coverage or policy questions
Members may contact Customer Service using the phone number on their member ID card to discuss benefits

Documentation Required

Required documentation and facility capabilities

Facilities must document capability and perform required clinical assessments at admission for withdrawal management and other high-acuity services. Evidence of drug screens, relevant labs, and baseline assessments must be in the record.

Facility capabilities: 24-hour access to medical evaluation, appropriate staffing, adherence to protocols, and credentialed personnel
Admission documentation: drug screens, relevant labs, and baseline clinical assessments

Documentation Required

Required clinical documentation at admission

At admission to withdrawal management or similar services, document current substances used (substance, duration, frequency, last use, quantity), urine drug monitoring or breathalyzer results, and at least three signs/symptoms of active moderate withdrawal or history indicating need for 24-hour medical intervention.

Admission clinical documentation must include: substance(s) used, duration, frequency, last date of use, quantity per use, and objective toxicology/breathalyzer results
Document at least three signs/symptoms of active moderate withdrawal or history predictive of severe withdrawal

Note

Provider action and contacts

Providers should verify member benefits and eligibility, confirm prior authorization requirements, and follow plan-specific criteria. For questions about coverage or to initiate authorization, contact Select Health Provider Relations.

Verify member benefits and eligibility at the time of service; coverage depends on the member's individual benefit plan
For provider questions or authorization assistance call Select Health Provider Relations at 801-442-3692

Prior Authorization

Continuation requirements

Continuation requirements across services emphasize documented improvement, planned tapering/fading, ongoing caregiver participation, and periodic reassessment using validated scales. If progress is insufficient, the plan must be modified and reassessed prior to additional authorization.

Continuation requires Essential Elements to remain met and evidence of improvement or documented plan modification
Use validated scales (e.g., VABS-3, ABAS, VB-MAPP, ABLLS) to demonstrate progress and guide authorization decisions
Caregiver participation and documented training progress are required to continue authorization

Step Therapy

No explicit step therapy rules specified

No explicit generic step therapy rules are specified for many interventions in this policy. Where medication trial requirements are specified (for example, TMS), document prior medication trials per the stated medication-failure criteria rather than applying an unrelated step-therapy algorithm.

TMS medication-trial requirements: document prior antidepressant trials per policy (number, duration, agent classes) as applicable
When policy does not specify step therapy, follow the documented clinical criteria and member benefit requirements

Step Therapy

Medication trial / step therapy considerations

Some policies incorporate medication-trial or step requirements as a condition of coverage (e.g., TMS requires documented trials of antidepressant medications with specified durations and classes). Providers must include prescriber, medication names, durations, and reasons for discontinuation or intolerance in the record.

TMS: Document failure of medication therapy per criteria — e.g., for new-onset depression, at least 4 antidepressant courses from ≥2 classes within 24 months (or documented intolerance); for chronic/recurrent depression, at least 2 courses from ≥2 classes within 12 months (per policy specifics)
Documentation must include prescriber, medication name, dose/duration, and reason for discontinuation

Note

Level progression and discharge

Level progression and discharge should follow ASAM or InterQual criteria where applicable. Discharge is appropriate when goals are met or member can be safely managed at a lower intensity; plans must include transition/fading criteria and aftercare arrangements.

Adhere to ASAM/InterQual criteria for level transitions and discharge decisions
Discharge based on resolution of symptoms permitting safe management at a lower level and documented tapering/fading criteria

Note

Medication-Assisted Treatment consideration

Consider Medication-Assisted Treatment (MAT) for members with significant opioid dependence unless contraindicated. MAT should be integrated into the individualized treatment plan and documented with clinical rationale.

MAT should be critically considered for opioid dependence and integrated into care plans when appropriate
Document rationale if MAT is not used or is contraindicated

Policy references ICD‑10 codes F84.0 and F84.3–F84.9 for ASD diagnoses

Clinical variabilitySeverity and symptom presentation vary widely between individuals

Comprehensive ABA definition

DefinitionComprehensive ABA: direct treatment across many skill areas and domains to establish new skills or reduce challenging behaviors; access should not be restricted by age, cognitive level, diagnosis, or co‑occurring conditions.

ScopeEmphasizes establishing new skills and may address challenging behaviors such as elopement or stereotypy

Access guidancePolicy states comprehensive access should not be limited by age or diagnosis unless state mandates differ

Focused ABA definition

DefinitionFocused ABA: direct treatment targeting a limited number of domains or skill areas; access should not be restricted by age, cognitive level, diagnosis, or co‑occurring conditions.

Use caseAppropriate when there are one or two problem areas requiring targeted intervention

Unit mappingPolicy maps focused treatment to assessment/treatment unit examples (e.g., 16–24 units)

Chemical aversion therapy definition and agents note

DefinitionChemical aversion therapy: a behavior modification technique pairing substances with induced unpleasant symptoms to create conditioned aversions (agents include emetine, apomorphine, lithium).

Regulatory noteNone of the commonly used agents are FDA‑approved specifically for aversion therapy; medical observation is required when used.

Coverage contextPolicy describes use as part of coordinated treatment plans for Commercial/CHIP when applicable

EMDR definition

DefinitionEMDR: a psychotherapeutic technique using identification of traumatic memory, negative/positive cognition formulation, and sets of bilateral eye movements or other rhythmic stimulation to process distressing memories.

Primary indicationDeveloped for and empirically validated mainly for trauma‑related disorders such as PTSD

Mechanism and protocolInvolves an 8‑phase protocol in many trials and uses saccadic bilateral eye movements interspersed with cognitive processing

Hippotherapy definition

DefinitionHippotherapy: rehabilitative therapy using a horse or mechanical equine equipment intended to improve posture, walking, and related functional outcomes; sometimes proposed as equine‑facilitated psychotherapy.

Implementation noteGuidelines for implementation as psychotherapy are lacking in the literature

Provider typesMay be provided by PT, OT, SLP (with appropriate credentials), psychologist, or psychotherapist

EMDR (alternate phrasing) definition

Alternate phrasingEMDR: psychotherapy combining exposure, cognitive restructuring, and bilateral stimulation (eye movements, sound, touch) to reduce trauma‑related distress

Evidence noteEmpirically validated for trauma disorders; limited data for non‑PTSD indications—further research needed

Session elementsPatients identify target memory, negative/positive cognition, and engage in repeated bilateral stimulation sets with distress ratings

Hippotherapy / Equine-facilitated psychotherapy definition

DefinitionHippotherapy / Equine‑facilitated psychotherapy: therapeutic use of horseback riding/equine movement to achieve functional or psychotherapeutic goals; evidence for psychotherapy applications is inadequate.

EvidenceLiterature primarily small case series and small randomized trials; claims for psychotherapeutic benefit lack scientific support

Coverage stanceSelect Health does NOT cover hippotherapy for the listed indications (investigational) per policy

Mickel Therapy definition

DefinitionMickel Therapy: a one‑on‑one, spoken 'wellness' therapy consisting of hour‑long sessions at 1–3 week intervals providing education and guidance without medications or hands‑on modalities.

Evidence/coveragePolicy states Select Health does NOT cover Mickel Therapy for treatment of fibromyalgia (investigational/not covered)

ModalityFocused on re‑education of symptoms and self‑management through practitioner guidance

Treatment-resistant depression definition

DefinitionTreatment‑resistant depression: depression not responding to multiple antidepressant therapies; literature commonly defines as failure of ≥2 antidepressant trials.

Prevalence noteApproximately 25% of depressed patients may meet this definition in cited literature

Clinical relevanceTMS is discussed primarily as an option for treatment‑resistant MDD in policy criteria

nTMS definition

DefinitionnTMS: navigated transcranial magnetic stimulation — an MRI‑guided, noninvasive technique for high‑resolution motor and language cortical mapping used pre‑operatively.

SettingOutpatient procedure performed with MRI‑based navigation allowing mapping across age ranges (infancy to adult) with minimal discomfort

Clinical useUsed to inform surgical planning and may supplement intraoperative direct cortical stimulation

rTMS and dTMS definition

rTMS/dTMS definitionrTMS: repetitive transcranial magnetic stimulation — outpatient magnetic stimulation used for treatment‑resistant depression; dTMS (deep TMS) is a variant with limited primary studies.

Evidence summarySystematic reviews and primary studies support rTMS efficacy for treatment‑resistant MDD; dTMS evidence is limited and comparative effectiveness unclear

Typical protocolPolicy references typical TMS treatment plans of 36 sessions over ~10 weeks

UROD / OADUSA definition

DefinitionUROD / OADUSA: ultra‑rapid or anesthesia‑assisted opioid antagonist detoxification — induction of opioid detoxification using high‑dose antagonist (e.g., naloxone) under general anesthesia or heavy sedation, often with brief ICU hospitalization.

Procedure noteTypically a 4‑hour procedure in ICU with 1–2 days hospitalization when general anesthesia is used; may be offered outpatient if only heavy sedation used

Coverage stancePolicy deems UROD experimental/investigational and not covered for opioid dependence

Ambulatory WM definition (ASAM levels 1,2.1,2.5)

DefinitionAmbulatory WM (ASAM levels 1, 2.1, 2.5): organized outpatient medically‑supervised evaluation and withdrawal management for patients at low risk for severe withdrawal.

Service featuresDelivered in scheduled outpatient sessions by trained clinicians with medical oversight and protocols

Relation to ASAMSelect Health adheres to ASAM criteria for outpatient withdrawal management

Inpatient WM (ASAM level 4) definition

DefinitionInpatient WM (ASAM level 4): hospital‑level care with intensive medical oversight for active or high‑risk severe withdrawal.

Use caseFor patients with active severe withdrawal symptoms or potential for same requiring 24‑hour monitoring and medical/nursing care

Criteria adherenceSelect Health uses InterQual criteria for inpatient WM determinations

Medical personnel / qualified provider definition

Qualified providersMedical personnel/qualified provider = RN, NP, PA, MD, DO who can monitor withdrawal symptoms and implement physician‑approved protocols

Operational requirementsFacilities must provide 24‑hour access for evaluation/consultation and appropriate credentialed personnel and safe staffing

Documentation roleQualified providers are responsible for admission assessments, drug screens, and individualized treatment plans within 24 hours

CIWA definition and threshold reference

CIWA definitionClinical Institute Withdrawal Assessment for Alcohol (CIWA): score threshold in policy noted as 16 or above prompting consideration of transition to higher level of care.

UseApplied in Ambulatory Detoxification to trigger escalation when CIWA ≥16

ReferenceCIWA thresholds modified in revision history for Commercial Plan Policy (4/26/24)

COWS definition and threshold reference

COWS definitionClinical Opiate Withdrawal Scale (COWS): score threshold in policy noted as 36 or greater prompting consideration of transition to higher level of care.

UseApplied in Ambulatory Detoxification to trigger escalation when COWS ≥36

ReferenceCOWS thresholds modified in revision history for Commercial Plan Policy (4/26/24)

Providers should document and bill using the specified CPT codes (e.g., 0362T, 0373T, 97151–97158, 96202–96203).

Supervision and non-custodial care: Services must be provided or supervised by qualified behavior analysts or licensed psychologists where within scope; supervision minimum 5% of direct service hours and at least monthly; ABA is not custodial care.

If state/contract permits non-certified providers, appropriate supervision/direction required.

DocumentationClaims should include specific CPT codes and supporting documentation per billing/coding guidance

EMDR session lengths and billing note — no explicit visit limits provided; billing codes listed for session lengths

EMDR session lengths / billingEMDR‑related services commonly billed using psychotherapy CPT codes for 30, 45, and 60 minute sessions (90832, 90834, 90837) and H0004 per 15 minutes; policy provides no explicit visit limits.

Coding noteAlso lists interactive complexity (90785) and unlisted codes where applicable

Coverage contextCoverage of EMDR limited to PTSD per policy; non‑PTSD uses considered investigational

TMS treatment sessions — recommended 36 sessions over ~10 weeks

Recommended course countTMS treatment course typically recommended as 36 sessions delivered over ~10 weeks

Evidence basisPolicy and evidence summaries reference trials and reviews supporting 36 sessions as commonly used protocol

DocumentationTreatment plan should document intent for 36 treatments and clinical monitoring per TMS criteria

Ambulatory detoxification duration — intended duration of ambulatory detoxification without prior authorization (5-7 days)

Intended ambulatory durationAmbulatory detoxification intended for up to 5–7 days without prior authorization

Extension requirementTreatment beyond 7 days requires prior authorization with documentation and specific treatment goals

Service deliveryServices delivered face‑to‑face in regularly scheduled outpatient sessions by qualified personnel

2025-06-12exclusion_added

Commercial Plan Policy: added exclusion stating Select Health does not cover TMS for migraine headaches (considered experimental/investigational).

2025-03-10criteria_revision

Commercial Plan Policy: created TMS criteria #4A and #4B to distinguish medication-failure requirements for new onset/non-recurrent versus chronic/recurrent depression.

2024-07-17exclusion_added

Commercial Plan Policy: added exclusion that Select Health does NOT cover TMS for ages 17 and under (considered experimental/investigational).

2024-07-08criteria_revision

Commercial Plan Policy: modified requirements in TMS criteria #1 to #4 and added criterion #5 in section A-I to align with updated clinical standards.

2024-04-26threshold_revision

Commercial Plan Policy: modified Ambulatory Detoxification escalation thresholds for CIWA (16 or above) and COWS (36 or greater) prompting higher level of care.

2024-02-27clarification

Commercial Plan Policy: added clarifying language to TMS criterion #4a regarding documented failure and prescriber requirements for antidepressant trials.

2024-02-27administrative_update

Commercial Plan Policy: additional editorial updates referenced in revision history (see entries for 2/27/24).

The codes listed in this policy are provided for informational purposes. Inclusion or exclusion of codes does not imply member coverage or guarantee reimbursement; providers should verify member benefits and eligibility and refer to the member contract or contact Select Health Provider Relations for questions. This disclaimer is placed prominently near the revision and billing sections.