Clinical UM Guideline
|Subject:||Applied Behavioral Analysis for Autism Spectrum Disorder|
|Guideline #:||CG-BEH-02||Current Effective Date:||07/01/2014|
|Status:||Reviewed||Last Review Date:||02/13/2014|
This guideline addresses the use of Applied Behavioral Analysis (ABA) or similar services that utilize intensive behavioral intervention (collectively, ABA), when included in relevant state mandates, as treatment for Autism Spectrum Disorder (ASD) when a state mandate requires or benefit plan language explicitly provides coverage for ABA.
The diagnosis of ASD can be complex and difficult due to the diversity of the presentation of symptoms and their severity. Due to the multitude of possible causes and potential confusion with other conditions, many tests exist to diagnose ASD that may or may not be appropriate. It is vital that parents or guardians of children suspected of having an ASD seek early diagnosis and care for the child to increase any potential benefits of treatment. The recommendations for evaluation and assessment of Autism Spectrum Disorders as published by the American Academy of Neurology (Filipek, 2000), the Child Neurology Society and the American Academy of Pediatrics (Johnson, 2007) and the American Academy of Child and Adolescent Psychiatry (Volkmar,1999) are good resources to utilize.
Autism spectrum disorder, as defined in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes disorders previously referred to as:
Note: Benefits, state mandates and regulatory requirements should be verified prior to application of criteria listed below.
Note: For information regarding testing or treatment of ASD and other related conditions, please see:
|Criteria for Coverage|
An initial course of ABA treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met:
Continuation of ABA treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met:
* During ABA treatment, an individual's progress should be measured using standardized assessment tools with known normative data. Such tests should have age-specific norms against which the individual's progress is measured. For example, using the Vineland, the results are reported in standard scores. The results can be compared from two points in time to see if the standard scores showed improvement.
Supervision of behavior analysts providing ABA treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL of the following selection criteria are met:
ABA treatment will not be covered when the criteria above are not met or when there is no documentation of clinically significant developmental progress in any one of the following areas: social skills, communication skills, language skills, or adaptive functioning as measured by either a) interim progress assessment or b) developmental status as measured by standardized tests.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
Note: There are no specific procedure codes for ABA therapy. The following list of procedure codes are examples only and may not represent all codes being used for ABA therapy. Please contact the member's plan for applicable coding conventions as these may vary.
|0359T||Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report|
|0360T||Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient|
|0361T||Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient|
|0362T||Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient|
|0363T||Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient|
|0364T||Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time|
|0365T||Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time|
|0366T||Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time|
|0367T||Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time|
|0368T||Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time|
|0369T||Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time|
|0370T||Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)|
|0371T||Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)|
|0372T||Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients|
|0373T||Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient|
|0374T||Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time, face-to-face with patient|
|For the following codes, when specified as ABA therapy:|
|H0031||Mental health assessment by non-physician|
[when specified as functional assessment and treatment plan developed for Applied Behavior Analysis (ABA) services by a Qualified Autism Service Provider (licensed clinician or Board Certified Behavioral Analyst (BCBA))
|H0032||Mental health service plan development by non-physician|
[when specified as supervision of a Qualified Autism Service Professional or Paraprofessional by a Qualified Autism Service Provider]
|H0046||Mental health services, not otherwise specified|
[when specified as direct ABA services by a Qualified Autism Service Professional]
|H2012||Behavioral health day treatment, per hour|
[when specified as direct ABA services by a Qualified Autism Service Provider]
|H2014||Skills training and development, per 15 minutes|
[when specified as skill development, social skills group activity]
|H2019||Therapeutic behavioral services, per 15 minutes|
[when specified as direct ABA services by a Qualified Autism Service Paraprofessional]
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|299.10-299.11||Childhood disintegrative disorder|
|299.80-299.81||Other specified pervasive developmental disorders (Asperger's disorder)|
|299.90-299.91||Unspecified pervasive developmental disorder|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|F84.3||Other childhood disintegrative disorder|
|F84.8||Other pervasive developmental disorders|
|F84.9||Pervasive developmental disorder, unspecified|
In May 2013, the American Psychiatric Association (APA) released the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This edition of the DSM includes several significant changes over the previous edition, including combining several previously separate diagnoses under the single diagnosis of "autism spectrum disorder" (ASD). This diagnosis included the following disorders, previously referred to as: atypical autism, Asperger's disorder, childhood autism, childhood disintegrative disorder, early infantile autism, high-functioning autism, Kanner's autism, and pervasive developmental disorder not otherwise specified. All of these conditions are now considered under one diagnosis, ASD. It should be noted that Rett Syndrome is not included in the new DSM-5 ASD diagnostic group.
The DSM-5 describes the essential diagnostic features of autism spectrum disorder as both a persistent impairment in reciprocal social communication and restricted and repetitive pattern of behavior, interest or activities. These attributes are present from early childhood and limit or impair everyday functioning. Parents may note symptoms as early as infancy, and the typical age of onset is before 3 years of age. Symptoms may include problems with using and understanding language; difficulty relating to or reciprocating with people, objects, and events; lack of mutual gaze or inability to attend events conjointly; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings, and repetitive body movements or behavior patterns. There are some exceptions to this, where in some circumstances a child may exhibit normal development for approximately 2 years followed by a marked regression in multiple areas of function.
Children with ASD vary widely in abilities, intelligence, and behaviors. Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development. Repetitive play skills, resistance to change in routine and inability to share experiences with others, and limited social and motor skills are generally evident. Unusual responses to sensory information, such as loud noises and lights, are also common. Affected children can exhibit unusual behaviors occasionally or seem shy around others sometimes without having ASD. What sets children with ASD apart is the consistency of their unusual behaviors. Symptoms of the disorder have to be present in all settings, not just at home or at school, and over considerable periods of time. With ASD, there is a lack of social interaction, impairment in nonverbal behaviors, and a failure to develop normal peer relations. A child with an ASD tends to ignore facial expressions and may not look at others; other children may fail to respect interpersonal boundaries and come too close and stare fixedly at another person.
ASDs, under the new DSM-5 paradigm, are now classified by Severity Level (see Table 2 below). Level 1, "Requiring support," is considered the least severe classification and includes individuals with mild deficits in social communications (as seen in individuals formerly diagnosed with Asperger's syndrome). Level 3, "Requiring very substantial support," is considered the most severe classification and includes individuals with no or extremely limited communication abilities.
The exact causes of autism are unknown, although genetic factors are strongly implicated. A study released by the Centers for Disease Control and Prevention (2012) indicates that the incidence of ASD was as high as 1 in 88 children.
The specific DSM-5 diagnostic criteria for ASD are provided below:
DSM-5 Criteria for Autism Spectrum Disorder*
Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.
Specify current severity:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor (Coding note: Use additional code to identify the associated medical or genetic condition)
Associated with another neurodevelopmental, mental, or behavioral disorder. (Coding note: Use additional code[s] to identify the associated neurodevelopmental, mental, or behavioral disorder)
With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120 for definition). (Coding note: Use additional code 293.89 [F06.1] catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia).
* From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. American Psychiatric Association. Washington, DC. May 2013. Pages 50-51.
|Table 2 Severity levels for autism spectrum disorders*|
|Severity Level||Social Communication||Restricted, repetitive behaviors|
"Requiring very substantial support"
|Severe deficits in verbal and nonverbal social communications skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches.||Inflexibility of behavior, extreme difficulty coping with change, or other restricted / repetitive behaviors markedly interfere with functioning in all spheres. Great distress / difficulty changing focus or action.|
"Requiring substantial support"
|Marked deficits in verbal and nonverbal communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication.||Inflexibility of behavior, difficulty coping with change, or other restricted / repetitive behaviors appear frequently enough to be obvious to the casual observer in a variety of context. Distress and or difficulty changing focus or action.|
|Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communications but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.||Inflexibility of behavior cases significant interference with functioning in one or more context. Difficulty switching between activities. Problems of organization and planning hamper independence.|
* From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. DSM-5. American Psychiatric Association. Washington, DC. May 2013. Page 52.
The treatment of ASD may take many different approaches, focusing on one or more aspects of the condition being treated. There is no single treatment that has consistently demonstrated benefit at the core symptoms of these disorders. Family therapy is generally supported as a valuable treatment because it offers emotional support and guidance to parents who will contend with a myriad of services to assist their child. Individual therapy using social story technique and behavioral cue coaching are very useful for the older child/adolescent with Asperger's syndrome and can make a difference in that child's acceptance by others. Educational therapy includes intensive one-on-one therapy involving a wide array of techniques focusing on improvement in social, communication, and language skills, and may include ABA.
When ABA is used, it may focus on the treatment of multiple behavioral targets across all developmental domains (Comprehensive ABA) or may focus on a limited number of behavioral targets in a select number of domains (Focused ABA). Comprehensive ABA may range from 26-40 hours per week, including supervision, in a one-to-one setting with the treated individual and an ABA Analyst. As treatment progresses, treatment in group settings may also be appropriate. One example of this type of treatment is early treatment where the goal is to close the gap between an individual and their typically developing peers. These goals may focus on cognitive communication, social, and emotional domains as well as on the symptoms of co-occurring behavior disorders such as aggression or self injury. Older individuals with ASDs may be reasonable candidates for Comprehensive ABA, especially if they engage in severe or dangerous behaviors across environments. Focused ABA involves one-on-one treatment and is not restricted by age or other factors. It is used to attain specific goals where an individual is lacking functional skills, such as are needed in establishing compliance with medical and dental procedures, sleep hygiene, self care, or safe and independent leisure skills. Focused ABA treatment is usually 10 to 25 hours weekly.
With regard to the hours of supervision of behavior analysts providing ABA treatment, the Behavior Analyst Certification Board guidelines for Health Plan Coverage of Applied Behavior Analysis Treatment for Autism Spectrum Disorder (2012) states the following:
Although the amount of supervision for each case must be responsive to individual client needs, 1-2 hours for every 10 hours of direct treatment is the general standard of care. When direct treatment is 10 hours per week or less, a minimum of 2 hours per week of clinical management and case supervision is generally required. Clinical management and case supervision may need to be temporarily increased to meet the needs of individual clients at specific time periods in treatment (e.g., intake, assessment, significant change in response to treatment).
Note: State mandates or certificate language may define these terms more or less broadly than below; consult applicable mandates and certificates when applying this guideline.
Applied Behavior Analysis (ABA): ABA refers to the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior. ABA methods are used to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. ABA focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community (Meyers, 2007).
Assessment instruments: Specialized and standardized diagnostic test used to evaluate an individual's performance in specific areas of functioning such as those recommended in the guidelines of the AAP, AAN and the AACAP (e.g., learning and communications skills, social interaction, etc.).
Autism Spectrum Disorder: A collection of associated developmental disorder that affect the parts of the brain that control social interaction and verbal and non-verbal communication.
Behavior modification: A therapy type that is designed to create new behavior patterns in people through intensive and frequent feedback using a reward, non-reward system.
Educational interventions: Learning interventions that assist children with obtaining knowledge, communication through speech, sign language, writing and other methods and social skills. Note: Many benefit contracts exclude coverage for services that are educational in nature.
Oversight/supervision of treatment: ABA is usually conducted by many different individuals, all of whom are tasked with implementing a treatment plan created by a licensed or certified behavioral analyst. To assure that the treatment plan is being properly and effectively implemented, the licensed or certified provider is required to conduct regular direct supervision sessions of the individuals conducting the ABA treatments specified by the treatment plan for the individual with an autism spectrum disorder.
Rett Syndrome: A developmental disorder that affects the parts of the brain that control social interaction, communications and motor function.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Applied Behavioral Analysis (ABA)
Early Intensive Behavior Intervention (EIBI)
Intensive Behavior Intervention (IBI)
Pervasive Developmental Disorder (PDD)
|07/01/2014||Updated Coding section with 07/01/2014 CPT changes.|
|Reviewed||02/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Reviewed||02/07/2014||Behavioral Health Subcommittee review. No change to Clinical Indications.|
|New||10/18/2013||Behavioral Health Subcommittee review. Initial document development.|