Clinical UM Guideline
|Subject:||Adaptive Behavioral Treatment for Autism Spectrum Disorder|
|Guideline #:||CG-BEH-02||Current Effective Date:||08/18/2016|
|Status:||Revised||Last Review Date:||08/04/2016|
IMPORTANT INFORMATION ABOUT THIS GUIDELINE:
This guideline is to be applied to the extent there is a state mandate or specific benefit coverage for an Adaptive Behavioral Treatment (ABT) such as Intensive Behavioral Intervention (IBI) or Applied Behavioral Analysis (ABA) for Autism Spectrum Disorder (ASD).
This document addresses the treatment of ASDs and other Pervasive developmental disorders (PDDs) with behavioral interventions such as ABA when a state requires or benefit language explicitly provides coverage for the behavioral intervention(s). In this document, the term 'ABT,' which includes services such as ABA and IBI, refers to services that may be provided as part of ABA and IBI.
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 ASD as published by the American Academy of Pediatrics (Zwaigenbaum, 2015b), and the American Academy of Child and Adolescent Psychiatry (Volkmar, 2014) are resources that can be utilized.
ASD, 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:
I. Assessment and Planning
The assessment and planning for an initial course of behavioral intervention services may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria are met:
One or more of the following ABT behavioral assessments may be covered when any of the criteria above have been met and the specific criteria for each type of assessment below have been met:
II. Adaptive Behavioral Treatment (ABT)
Adaptive behavior treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria have been met:
Protocol modification of ABT treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria are met:
Group adaptive behavior treatment may be covered when all of the following criteria have been met:
Adaptive behavior treatment social skills group may be covered when all of the following criteria have been met:
Family adaptive behavior treatment guidance may be covered when all of the following criteria have been met:
Multiple-family group adaptive behavior treatment guidance may be covered when all the following criteria have been met:
Exposure adaptive behavior treatment with protocol modification may be covered when all of the following criteria have been met:
III. Continuation of treatment
Continuation of ABT treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria are met:
Note: The number of hours allotted for direct treatment with the individual can continue to be up to 40 hours a week. The hours should be reviewed regularly, and adjusted to address the behavioral targets and key functional skills of the individual, based on the results of the assessments mentioned above.
* Systematic and repeated evaluation of developmental status is critical to assessing the effect of therapeutic treatments, including ABT. The use of standardized assessments facilitates the consistent, systematic, and reliable evaluation early in the course of treatment, preferably before initiating ABT, and at regularly scheduled intervals thereafter. The data derived from these assessments is used to inform about the impact of treatment on the trajectory of the individual's condition, especially documenting improvement. Examples of widely accepted and used standardized assessments include the VB-MAPP and the Vineland.
IV. When Above Criteria Are Not Met
To the extent there is a state mandate or specific benefit coverage for ABT for an individual that allows ABT treatment to be reviewed using clinical criteria, ABT will be considered not covered and not medically necessary when either:
V. Other Information:
Cognitive, developmental or intelligence quotient (IQ) testing is not required for an initial or continued course of ABT treatment to be covered.
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 ABT. The following list of procedure codes are examples only and may not represent all codes being used for ABT. 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 ABT therapy:|
|G9012||Other specified case management services not elsewhere classified|
|H0031||Mental health assessment by non-physician [when specified as functional assessment and treatment plan developed for Adaptive Behavioral Treatment (ABT) 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 ABT services by a Qualified Autism Service Professional]
|H2012||Behavioral health day treatment, per hour|
[when specified as direct ABT 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 ABT services by a Qualified Autism Service Paraprofessional]
|S5108||Home care training to home care client, per 15 minutes|
|S5110||Home care training, family; per 15 minutes|
|F84.3||Other childhood disintegrative disorder|
|F84.8||Other pervasive developmental disorders|
|F84.9||Pervasive developmental disorder, unspecified|
In May 2013, the APA released 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 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 PDD 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 ASD 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 ABT.
ABT should be part of person-centered treatment plan that addresses the whole person. The plan is developed based on assessments of the individual's behavioral, psychological, family, and medical health. The use of ABT begins with a thorough assessment of the individual for whom the treatment is requested. This assessment should include confirmation of a diagnosis of ASD made by a licensed medical professional, licensed psychologist, or other qualified health care professional. The evaluation of motor, language, social, adaptive, and/or cognitive functions is important to understand the individual's baseline status and potential for improvement (Maglione, 2012). State mandates may limit the assessments that a health plan may require.
In order to assure accurate measurement of progress and outcomes, the treatment plan must utilize measurable goals in objective and measurable terms based on standardized assessments that address the behaviors and impairments for which the intervention is to be applied (Maglione, 2012). The use of standardized assessments in a systematic and repeated manner is critical to the proper and consistent measurement of an individual's response to treatment. Standardized assessments, as opposed to non-standardized assessments, are important because standardized assessments have been demonstrated to be consistent, reliable, and widely available. Furthermore, many have been validated for clinical accuracy as well. The use of standardized assessments early in the course of treatment, preferably before initiating treatment and at regularly scheduled intervals thereafter, provides information about any impact of treatment on developmental trajectory, especially documenting improvement. Examples of widely accepted and used standardized assessments include the VB-MAPP and the Vineland. These types of assessments usually consist of multiple sets of questions focusing on a variety of different developmental areas including, physical, language, social, and learning, and are intended to provide a clinical picture of an individual at a particular point in time.
The assessments characteristic of ABT can be classified into 3 types. A behavior identification assessment is used to identify behavioral issues that may be targeted for specific interventional treatment. There are many different assessment tools available for this type of assessment, and utilization of such a tool is critical for the proper identification and evaluation of behavioral issues. Examples of such tools include the VB-MAPP and the Vineland. Another assessment that may be required is an observational behavioral assessment. This type of assessment is used in the identification and evaluation of disruptive behaviors such as repetitive gestures, head banging, angry or violent outbursts, etc. According to the Behavior Analyst Certification Board (BCAB) document titled, Applied Behavior Analysis Treatment for Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2014), this initial assessment should take approximately 20 hours. Additionally, these assessments may need to be repeated during the treatment period, but are likely to take considerably less time to complete when repeated. An exposure behavioral assessment may be needed to further assess and characterize disruptive behaviors in order to understand social or environmental triggers of disruptive behaviors. Safety is very important. The environment in which these types of assessments are conducted should be carefully controlled, including the persons present at the time of evaluation. This is important in order to control for potential confounding elements that may interfere with proper assessment. Additionally, because aggressive or violent behaviors are often the types of disruptive behaviors for which this type of assessment is needed, there may be considerably risk to those present during the assessment period. In order to control for possible risk of harm, the assessment should be conducted in an environment that is away from areas that put others at unnecessary risk.
According to the BACB's 2014 guideline, comprehensive ABT should include one-on-one treatment with a certified or licensed physician, qualified healthcare provider, or ABT technician of between 30 to 40 hours per week. This recommendation is joined by the recommendations made in guidelines addressing non-medical interventions published by the Health Resources and Services Administration (HRSA, Maglione, 2012), which states that "Children with ASD should be actively engaged in comprehensive intervention for a minimum of 25 hours per week throughout the year." They support this with the comment that "the vast majority of high-quality behavioral interventions found in the literature required 20 to 40 hours of treatment per week."
Comprehensive treatment, including ABT, refers to treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypical actions are also typically the focus of treatment (Maglione, 2012). Comprehensive ABT treatment may be referred to as adaptive behavior treatment or adaptive behavior treatment with protocol modification.
Comprehensive ABT may involve several additional focused treatment methods tailored to address specific aspects of the individual's condition. According to the BACB's guidelines, focused treatments generally involve between 10 and 25 hours per week. One type of focused treatment is group adaptive behavior treatment, which targets maladaptive behaviors and skill deficits in a group setting. According to the HRSA, such group therapy has been found to be especially effective in older children (Maglione, 2012). Another type of focused treatment is family adaptive behavior treatment guidance, which is tended to provide instruction to a parent, guardian, or other caregiver in the treatment protocols designed to reduce maladaptive behaviors. Multiple-family group adaptive behavior treatment guidance is intended for the same purpose, but the goal is to train a group of parents, guardians, or caregivers together. These types of family-oriented therapies are recommended in HRSA guidelines (Maglione, 2012). Exposure adaptive behavior treatment with protocol modification is intended to focus on the treatment of specific disruptive behaviors such as gesturing or aggression.
Many of the treatments utilized in ABT are conducted by behavior analysts and technicians who may not be licensed, depending upon the laws and regulatory requirements of the area in which they are practicing. Supervision of behavior analysts and technicians by a licensed or certified professional is a requirement in the 2014 BACB guidelines, which states 2 hours of supervision for every 10 hours of direct treatment is the general standard of care.
The continuation of ABT is based upon the individual's continuing to meet the criteria used to qualify the initial course of treatment. Additionally, is it critical that the individual's person-centered treatment plan be updated, generally every 6 months, or as required by a state mandate, to provide adequate track of the individual's progress. Exposure assessments and interventions should suggest changes in the treatment plan because these evaluations and interventions are particularly intense and indicated when behavior poses a safety risk. The person-centered treatment plan should include age-specific and impairment appropriate goals and measures of progress as well as measures of the progress made with social skills, communication skills, language skills, adaptive functioning, and specific behaviors or deficits targeted. The measurement of progress in social skills, communication skills, language skills, and adaptive functioning should be measured by standard scores using standardized assessments no less frequent than every 2 years.
Finally, the benefit of ABT in the absence of clinically significant developmental progress has not been demonstrated in the peer-reviewed published literature. When no measurable benefit has been discerned through accepted and validated measurement tools, the use of ABT is not warranted.
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.
Adaptive Behavior Treatment (ABT): ABT 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. ABT 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. ABT focuses on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community. Applied Behavioral Analysis (ABA) is one type of ABT (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 disorders 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 and 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: ABT 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 ABT treatments specified by the treatment plan for the individual with an autism spectrum disorder.
Qualified health care professional: An individual who has earned the appropriate education, training, certifications and/or licensure in a field related to the treatment of autism and is considered qualified under the laws of their state to be qualified to oversee ABT.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Adaptive Behavioral Treatment (ABT)
Applied Behavioral Analysis (ABA)
Early Intensive Behavior Intervention (EIBI)
Intensive Behavior Intervention (IBI)
Pervasive Developmental Disorder (PDD)
|Revised||08/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||07/29/2016||Behavioral Health Subcommittee review. Created new section titled "When Above Criteria Are Not Met" and placed related text within that section. Added text regarding state mandates. Updated formatting in the Clinical Indications section. Updated the Description, Discussion, Definitions, and Reference sections.|
|Revised||12/11/2015||Behavioral Health Subcommittee review. Revised Clinical Indications section regarding use of assessments. Updated Coding, Discussion/General Information and Reference sections. Removed ICD-9 codes from Coding section.|
|Revised||07/31/2015||Behavioral Health Subcommittee review. Revised and restructured Clinical Indications section. Updated Background, Definitions, and Reference sections.|
|Reviewed||01/30/2015||Behavioral Health Subcommittee review. Description and References updated.|
|07/01/2014||Updated Coding section with 07/01/2014 CPT changes.|
|Reviewed||02/07/2014||Behavioral Health Subcommittee review.|
|New||10/18/2013||Behavioral Health Subcommittee review. Initial document development.|