Coverage Policy Manual
Policy #: 2011053
Category: Medicine
Initiated: July 2011
Last Review: February 2019
  Autism Spectrum Disorder, Applied Behavioral Analysis

Description:
Autism spectrum disorder (ASD) is a complex, pervasive developmental disability characterized by variable social and communicative deficits with repetitive, restricted behaviors and for many, significant cognitive impairment. The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, Text Revision (DSM-V-TR) specifies autistic disorder, pervasive developmental disorder---not otherwise specified (PDD-NOS), and Asperger’s syndrome as included under the diagnosis of ASD. DSMV coalesces all of these diagnoses into Autism spectrum Disorder. The Center for Disease Control (CDC) estimates the prevalence of ASD as 1 out of every 68children occurring in all ethnic, racial, and socioeconomic groups but 4-5 times more likely in boys than girls. A CDC report published in 2009, demonstrated that an average of 41% of ASD individuals met a definition of intellectual disability.
 
Applied Behavioral Analysis (ABA) is the behavioral treatment approach most commonly used with children with ASD. Techniques based on ABA include: Discrete Trial Training, Incidental Teaching, Pivotal Response Training, and Verbal Behavioral Intervention. ABA involves a structured environment, predictable routines, individualized treatment, transition and aftercare planning, and significant family involvement. ABA attempts to increase skills related to behavioral deficits and reduce behavioral excesses. Behavioral deficits may occur in the areas of communication, social and adaptive skills, but are possible in other areas as well. Examples of deficits may include: a lack of expressive language, inability to request items or actions, limited eye contact with others, and inability to engage in age-appropriate self-help skills such as tooth brushing or dressing. Examples of behavioral excesses may include, but are not limited to: physical aggression, property destruction, elopement, self-stimulatory behavior, self-injurious behavior, and vocal stereotypy. Several discipline- specific intensive intervention programs have been developed and advocated for the treatment of autism (Lovaas therapy, Early Start Denver Model, and others).
 
ABA treatment is considered either comprehensive or focused based on the core symptoms targeted and the intensity of the intervention.
 
Comprehensive Treatment
Comprehensive ABA treatment targets members whose treatment plans address deficits in all of the core symptoms of Autism. Appropriate examples of comprehensive treatment include: early intensive behavioral intervention and treatment programs for older children with aberrant behaviors across multiple settings. This treatment is primarily directed to children ages 3 to 8 years old because comprehensive ABA treatment has been shown to be most effective with this population in current medical literature.
 
The goals of this treatment are to improve communication, cognitive skills, social interaction, and adaptive behavior. The American Academy of Pediatrics released clinical reports in 2007 dealing with both the diagnosis of ASD and its management. The educational interventions mentioned included both behavioral and habilitative strategies concentrating on the development of communication skills, socialization skills, adaptive skills, and control or ablation of disruptive behaviors. The authors note that early childhood educational programs are built on several models, including behavior analysis, developmental, or structured teaching. Recommendations for such programs included the following:
 
    • Children should be entered in an early childhood educational program as soon as possible
    • The intervention should be highly structured and intensive, with child actively involved initially at least 25 hours per week for 12 months per year;
    • The member-to-service provider ratio is low enough to allow “sufficient” amounts of 1:1 time and small group instruction;
    • Parent training is an essential component of Comprehensive ABA treatment.
    • Opportunities to generalize learning and interact with typically developing peers should be provided;
    • There should be ongoing standardized measurement of the child’s progress and changes in approach when indicated; and
    • The domains of communication, social skills, functional adaptive behavioral skills, cognitive skills, and pre-academic readiness skills, as developmentally indicated.
 
Focused Treatment
Focused treatment requests are typically up to 15 total hours per week based on the member’s severity, intensity and frequency of symptoms, and may include parent training as the only component.
 
Focused treatment typically targets a limited number of behavior goals requiring substantial support. Behavioral targets include marked deficits in social communication skills and restricted, repetitive behavior such as difficulties coping with change. In cases of specific aberrant and/or restricted, repetitive behaviors, attention to prioritization of skills is necessary to prevent and offset exacerbation of these behaviors, and to teach new skill sets. Identified aberrant behaviors should be addressed with specific procedures outlined in a Behavior Intervention Plan. Emphasis is placed on group work and parent training to assist the member in developing and enhancing his/her participation in family and community life, and developing appropriate adaptive, social or functional skills in the least restrictive environment.
 
Coding
 
Effective January 1, 2019, there are new CPT category I codes for applied behavioral analysis and are billed in 15 minute units. These services were previously billed with Category III codes in 30 minute or 1 hour units.  Coding instructions using the new CPT category I codes are listed below in the Policy/Coverage section.
 
*See additional detailed coding instructions in the Policy/Coverage section below
 
Related policy: 2011054 - Autism Spectrum Disorder Interventions other than Early Behavioral Intervention.

Policy/
Coverage:
COVERAGE EFFECTIVE JANUARY 1, 2019
 
This policy applies only to those contracts that provide a benefit for Applied Behavioral Analysis in the treatment of Autism Spectrum Disorder.
 
Applied behavioral analysis meets primary coverage criteria  for individuals with a confirmed diagnosis of autism spectrum disorder and a signed prescription from a licensed physician or licensed psychologist for ABA treatment in accordance with the ALL of the below parameters and guidelines:
 
    1. ABA must be provided or supervised by a therapist certified by the nationally accredited Behavior Analyst Certification Board; AND
    2. For "Grandfathered" plans, ABA shall have an annual limitation of $50,000; OR
    3. For “Non-grandfathered” plans, ABA shall have limits as outlined in the policy and coding guidelines.
 
Parameters for Comprehensive Treatment*:
 
    1. Children Age: 18 months up to 7 years of age,  AND  
    2. Duration: 3 years consecutively (e.g. child diagnosed at age 6 could have services through age 9), AND  
    3. Intensity:  minimum of 25 hours per week to maximum of 40 hours per week** of direct (line) services by behavioral technician or BCBA equivalent.
 
OR
  
Parameters for Focused Treatment*:
 
    1. Children Age: 18 months to < 18 years, AND  
    2. Duration:  36 months, AND  
    3. Intensity:  minimum of 10 hours per week to a maximum of 25 hours per week of direct (line) therapy services by a behavioral technician or BCBA equivalent.
 
Prior Approval of Services:  
 
All requests for coverage of ABA treatment will require Prior Approval.  Prior Approval  means that services are reviewed and meet all of the coverage criteria defined in this policy.  Prior Approval should be done prior to services being provided. New Directions Behavioral Health will administer Prior Approval and concurrent review of all ABA services for contracts with this benefit.
 
*Comprehensive and Focused Treatment cannot be provided concurrently.
 ** In very limited situations where additional hours are determined to meet primary coverage criteria,
 
New Directions Behavioral Health may authorize additional direct service hours as directed.
 
For all other diagnoses and indications, applied behavioral analysis does not meet primary coverage criteria and is not covered.
 
Policy Guidelines:
 
ABCBS will require a multidisciplinary evaluation to include, at a minimum, formal testing and assessment by the following providers (who are not employed by the child’s educational institution):
 
    1. A developmental pediatrician, pediatric neurologist, or child psychiatrist (or pediatrician with advanced training in focused developmental evaluations); and
    2. A licensed speech therapist with specialized training/experience in developmental pediatrics; and
    3. A licensed child psychologist with advanced training/experience in developmental pediatrics
 
Suggested testing by the multidisciplinary team normally includes:
 
    1. Autism specific testing (ADOS, ADI-R CARS, etc.)
    2. Hearing evaluation
    3. Speech/language/communication assessment (Peabody Picture Vocabulary test {PPVT}, Expressive Vocabulary Test {EVT}, etc
    4. Developmental/cognitive testing (IQ, for instance Bayley Scales of Infant development, WECHSLER PRESCHOOL AND PRIMARY SCALE OF INTELLIGENCE, etc)
    5. Adaptive behavioral evaluation (VABS, ABAS)
    6. Sensorimotor evaluation
    7. Laboratory work as suggested by assessment (fragile x, serum lead, etc.)
 
For those plans subject to Act 196 of the General Assembly of the State of Arkansas enacted as of October 1, 2011, the coverage of Applied Behavioral Analysis (ABA) may be subject to other general exclusions and limitations of the health insurance plan, including without limitation, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of health care services including review of medical necessity, case management, and other managed care provisions.
 
Coverage Criteria for ABA services for eligible members:
 
ABA TREATMENT ASSESSMENT
 
New Directions may authorize an ABA services assessment only if all of the following criteria are met:
 
    1. Diagnostic Criteria as set forth in the current DSM are met.
    2. Hours requested are not more than what is required to complete the treatment assessment
 
Note: Only CPT codes identified in this document will be approved for, the ABA assessment process. Standardized psychological testing services are billed with specific psychological testing AMA-CPT code by eligible providers.  Typically, a clinical psychologist is qualified to provide testing services.
 
INITIAL ABA SERVICE TREATMENT REQUEST
 
New Directions may authorize the initiation of ABA services for ASD only if all of the following criteria are met:
 
    1. The ABA services recommended do not duplicate or replicate services received in a member’s primary academic educational setting, or are available within an Individualized Education Plan (IEP) or Individualized Service Plan (ISP)  
    2. The ABA services recommended do not duplicate services provided or available to the member by other medical or behavioral health professionals.   
    3. Approved treatment goals and clinical documentation must be focused on active ASD core symptoms and deficits that inhibit daily functioning.  This includes a plan for stimulus and response generalization in novel contexts.
    4. When there is a history of ABA treatment, the provider reviews the previous ABA treatment record to determine that a reasonable expectation of that a member is able to, or demonstrates the capacity to learn and generalize skills to assist in his or her independence and functional improvements.
    5. For Comprehensive treatment, the requested ABA services are directed toward reducing the gap between the member’s chronological and developmental ages such that the member is able to develop or restore function to the maximum extent practical OR for Focused treatment the requested ABA services are designed to reduce the burden of selected treatment targeted symptoms on the member, family and other significant people in the environment, and to target increases in appropriate alternative behaviors.
    6. Treatment is provided at the least restrictive and most clinically approporate environment to safely, effectively and efficiently deliver care.
    7. Treatment intensity does not exceed the member’s functional ability to participate.
    8. Hours per week requested are not more than what is required to achieve the goals listed in the treatment plan and must reflect the member’s, caregiver’s, and provider’s availability to participate in treatment;.
    9. Treatment is clinically appropriate and designed to meet the individulaized needs of the member with regard to type, frequency, intensity, extent, site and duration of services.
    10. Treatment is required for reasons other than the convenience of the patient, parents/caregiver/guardian, or physician or other health care member.
    11. Treatment is not a substitute for non-treatment services addressing environmental factors.
    12. ABA treatment is not more costly than an alternate service or services, which will reasonably likely produce equivalent diagnostic or therapeutic results for the patient.
    13. ABA services are provided by a Board Certified Behavior Analyst (BCBA) or line therapist supervised by a BCBA.
    14. A comprehensive medical record is submitted by the BCBA to include:  
      • All initial assessments performed by the BCBA. Preferred assessments must be developmentally and age appropriate and include the ABLLS, VB-MAPP, or other developmental measurements employed. Only those portions of assessments or portions of assessments that cover academic, speech, vocational deficits, etc.;
      • Individualized treatment plan with clinically significant and measurable goals that clearly address the active symptoms and signs of the member’s core deficits of ASD.
      • Goals should be written with measurable criteria that can be reasonably achieved within six months.
      • Goals should include documentation of core symptoms of ASD identified on the treatment plan, date of treatment introduction, estimated date of mastery, and a specific plan for generalization of skills.
      • Functional Behavior Assessment to address targeted problematic behaviors with operational definition and provide data to measure progress, as clinically indicated.
      • Documentation of treatment participants, procedures and setting.
 
15. Caregiver participation in at least 80 percent of scheduled caregiver training sessions.  Caregiver training is defined as the education and development of caregiver-mediated ABA strategies, protocols, or techniques directed at facilitating, improving, or generalizing social interaction, skill acquisition and behavior management, to include observational measures for assurance of treatment integrity. It is recommended that one hour of parent training occurs for the first 10 hours of direct line therapy, with an additional 0.5 hours for every additional 10 hours of scheduled direct line therapy unless contraindicated or parent declines. Caregiver training requirements should increase to a higher ratio of total direct line therapy hours as increased number of member goals address activities of daily living, as provider plans for transition to lower level of care within the next 6 months or as member comes within one year of termination of benefits based on policy benefit restrictions. Caregiver training is necessary to address member’s appropriate generalization of skills, including activities of daily living, and to potentially decrease familial stressors by increasing member’s independence. ABA principles utilized during parent training to achieve desired outcomes may include, but are not limited to, reinforecement, task analysis, prompting, fading shaping and chaining.
16. Direct line therapy services are provided by an RBT, or BCaBA, supervised by a BCBA or BCBA-D or the provision of services is consistent with the controlling state mandate. In selected circumstances, direct one to one services provided by a BCBA or BCBA-D will be considered.
17. Although not required for the initial service request, transition and aftercare planning should begin during the early phases of treatment.
 
 CONTINUED SERVICE REQUEST
 
New Directions may authorize continued ABA treatment services for ASD only if all of the following criteria are met:
 
    1. The ABA services recommended do not duplicate or replicate services received in a member’s primary academic educational setting, or are available within an Individualized Education Plan (IEP) or Individualized Service Plan (ISP)
    2. The ABA services recommended do not duplicate services provided or available to the member by other medical or behavioral health professionals.
    3. Approved treatment goals and clinical documentation must be focused on active ASD core symptoms, substantial deficits that inhibit daily functioning, and clinically significant aberrant behavior. This includes a plan for stimulus and response generalization in novel contexts.
    4. Adaptive Behavior Testing (such as the Vineland Adaptive Behavior Scale (VABS), and Adaptive Behavior Assessment System (ABAS), Behavior Assessment System for Children: Adaptive Skills (BASC 3), Pervasive Developmental Disorder Behavior Inventory (PDDBI)) annually within a 45-day period before the next scheduled concurrent review dated. The Vineland or other standardized psychological tests may be required on any concurrent review dependent on clinical information obtained during the course of ABA treatment
    5. For comprehensive treatment, the requested ABA services are focused on reducing the gap between the member’s chronological and developmental ages such that the member is able to develop or restore function to the maximum extent practical OR For focused treatment the requested ABA services are designed to reduce the burden of selected treatment targeted symptoms on the member, family and other significant people in the environment, and to target increases in appropriate alternative behaviors.
    6. Treatment is provided at the least restrictive and most clinically appropriate environment to safely, effectively and efficiently deliver care.
    7. Treatment intensity does not exceed the member’s functional ability to participate.
    8. Hours per week requested are not more than what is required to achieve the goals listed in the treatment plan and must reflect the member’s, caregiver’s and provider’s availability to participate in treatment.
    9. Treatment is clinically appropriate and designed to meet the individualized needs of the member with regard to type, frequency, intensity, extent, site and duration of services.
    10. Treatment is required for reasons other than the convenience of the patient, parents/caregiver/guardian, or physician or other health care provider.
    11. Treatment is not a substitute for non-treatment services addressing environmental factors, nor primarily for custodial or respite care.
    12. ABA treatment is not more costly than an alternate service or services, which will reasonably likely produce equivalent diagnostic or therapeutic results for the patient.
    13. ABA services are provided by a Board Certified Behavior Analyst (BCBA) or line therapist supervised by a BCBA.
    14. A comprehensive medical record is submitted by the BCBA to include:
      • Collected data, including additional nonstandardized testing such as ABLLS, VB-MAPP or other developmentally appropriate assessments, celeration charts, graphs, progress notes that link to interventions of specific treatment plan goals/objectives. Only those portions of assessments that address core deficits of autism are reimbursable; this excludes assessments or portions of assessments that cover academic, speech, vocational deficits, etc.
      • Individualized treatment plan with clinically significant and measurable goals that clearly address the active symptoms and signs of the member’s core deficits of ASD.
      • Goals should be written with measurable criteria that can be reasonably achieved within six months.
      • Goals should include documentation of core symptoms of ASD identified on the treatment plan, date of treatment introduction, measured baseline of targeted goal, objective present level of behavior, mastery criteria, estimated date of mastery, a specific plan for generalization of skills, and the number of hours per week estimated to achieve each goal.
      • Functional Behavior Assessment to address targeted problematic behaviors with operational definition and provide data to measure progress, as clinically indicated.
      • Documentation of treatment participants, procedures and setting.
 
15. Caregiver participation in at least 80 percent of scheduled caregiver training sessions. Caregiver training is defined as the education and development of caregiver-mediated ABA strategies, protocols, or techniques directed at facilitating, improving, or generalizing social interaction, skill acquisition and behavior management, to include observational measures for assurance of treatment integrity. Caregiver training is necessary to address member’s appropriate generalization of skills, including activities of daily living, and to potentially decrease familial stressors by increasing member’s independence. Caregiver training goals submitted for each authorization period must be specific to the member’s identified needs and should include goal mastery criteria, data collection and behavior management procedures if applicable, and procedures to address ABA principles such as reinforcement, prompting, fading, and shaping. Each goal should include date of introduction, current performance level, and a specific plan for generalization. It is recommended that one hour of caregiver training occurs for the first 10 hours of direct line therapy, with an additional 0.5 hours for every additional 10 hours of scheduled direct line therapy unless contraindicated or caregiver declines. Caregiver training hours should increase to a higher ratio of total direct line therapy hours as increased number of member goals address activities of daily living, as provider plans for transition to lower level of care within the next 6 months or as member comes within one year of termination of benefits based on policy benefit restrictions.  Clinical rationale must be provided when less than 80 percent participation in scheduled caregiver training sessions occurs during a review period to address any deficits in member generalization of acquired skills into non-clinical community settings;
16. Transition and aftercare planning should begin during the early phases of treatment. Transition planning should focus on the skills and supports required for the member to transition into their normal environment as appropriate to their achieved and realistic developmental ability. The aftercare planning includes the identification of appropriate services and supports for the time period following ABA treatment. The transition planning process and documentation should include active involvement and collaboration with a multidisciplinary team. Goals must be developed specifically for the individual with ASD, be functional in nature, and focus on skills needed in current and future environments. The following information should be included:
      • Specific skills essential for both the family and member to succeed and how they are actively being addressed.
      • A detailed strategy for moving to less intensive ABA care detailing how hours will be faded connected to measurable objectives for family and member
      • The identification of appropriate community resources for the time period following ABA treatment to help support the family.
      • The identification of appropriate community resources to support the member’s ability to generalize skills to various environments.
17. Direct line therapy services are provided by an RBT, or BCaBA, supervised by a BCBA or BCBA-D or the provision of services is consistent with the controlling state mandate. In selected circumstances, ND will consider direct one to one services provided by a BCBA or BCBA-D.
18. On concurrent review, the current ABA treatment demonstrates significant Improvement and clinically significant progress to develop or restore the function of the member;
      • Significant improvement is: mastery of a minimum of 50 percent of stated goals found in the submitted treatment plan. New Directions may request further psychological testing be obtained to clarify limited/lack of treatment response. Adaptive behavior, cognitive and/or language testing must show evidence of measureable functional improvement, as opposed to declining or plateaued scores.
      • For members who do not master 50 percent of stated goals and/or fail to demonstrate measurable and substantial evidence toward developing or restoring the maximum function of the member, the treatment plan should clearly address the barriers to treatment success.
      • There is reasonable expectations of mastery of proposed goals within the requested six-month treatment period and that achievement of goals will assist in the member’s independence and functional improvements;
      • There is a reasonable expectation that a member is able to, or demonstrates the capacity to, acquire and develop clinically significant generalized skills to assist in his or her independence and functional improvements;
      • If the member does not demonstrate significant improvement or progress achieving goals for successive authorization periods, benefit coverage of ABA services may be reduced or denied
 
Caseload Size
 
The Behavioral Analyst Certification Board’s (“BACB”) Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers, 2nd Edition, [page 35], states that Behavior Analysts should carry a caseload that allows them to provide appropriate case supervision to facilitate effective treatment delivery and ensure consumer protection.
 
Caseload size for the Behavior Analyst is typically determined by the following factors:
 
    • Complexity and needs of the clients in the caseload
    • Total treatment hours delivered to the clients in the caseload
    • Total case supervision and clinical direction required by caseload
    • Expertise and skills of the Behavior Analyst;
    • Location and modality of supervision and treatment (for example, center vs. home, individual vs.group,)
    • Availability of support staff for the Behavior Analyst (for example, a BCaBA).
 
The recommended caseload range for one (1) Behavior Analyst is as follows:
 
Supervising Comprehensive Treatment
 
    • Without support of a BCaBA is 6 - 12.
    • With support of one (1) BCaBA is 12 - 16.
    • Additional BCaBAs permit modest increases in caseloads.
 
Definitions:
 
    • Clinical Significance: Clinical significance is the measurement of practical importance of a treatment effect-whether it creates a meaningful difference and has an impact that is noticeable in daily life.   
    • Core deficits of Autism: persistent deficits in social communication and social interaction across multiple contexts AND, restricted, repetitive patterns of behavior, interests, and activities
    • Generalization: skills acquired in one setting are applied to many contexts, stimuli, materials, people, and/or settings to be practical, useful, and functional for the individual. Generalized behavior change involves systematic planning, and needs to be a central part of every intervention and every caregiver training strategy.
    • Baseline data: objective and quantitative measures of the percentage, frequency or intensity and duration of skill/behavior prior to intervention
    • Mastery criteria: objectively and quantitatively stated percentage, frequency or intensity and duration in which a member must display skill/behavior to be considered an acquired skill/behavior.
    • Functional analysis: Empirically supported process of making systematic changes to the environment to evaluate the effects of the four testing conditions of play (control), contingent attention, contingent escape and the alone condition, on the target behavior, which allows the practitioner to determine the antecedents and consequences maintaining the behavior.
    • Functional Behavior Assessment: comprises descriptive assessment procedures designed to identify environmental events that occur just before and just after occurrences of potential target behaviors and that may influence those behaviors. That information may be gathered by interviewing the member’s caregivers; having caregivers complete checklists, rating scales or questionnaires; and/or observing and recording occurrences of target behaviors and environmental events in everyday situations (AMA CPT, 2019).  
    • Interpersonal Care: interventions that do not diagnose or treat a disease, and that provide either improved communication between individuals, or a social interaction replacement
    • Nonstandardized instruments:  include, but not limited to, curriculum-referenced assessment, stimulus preference- assessment procedures, and other procedures for assessing behaviors and associated environmental events that are specific to the Individual patient and behaviors (AMA CPT, 2019).
    • Standardized Assessments:  include, but not limited to, behavior checklists, rating scales, and adaptive skill assessment instruments that comprise a fixed set of items and are administered and scored in a uniform way with all patients.  (AMA CPT, 2019) The listed assessments are not meant to be exhaustive, but serve as a general guideline to quantify baseline intelligence and adaptive behaviors and when repeated, measure treatment outcomes.  The autism specific assessments assist not only in the confirmation of diagnosis but more importantly, in the severity and intensity of the baseline core ASD behaviors.
 
Excluded services:
 
The following services have insufficient or no evidence to support efficacy and do not meet coverage criteria:
 
    • Respite, shadow, para-professional, or companion services in any setting
    • Services that address or treat symptoms other than the core symptoms of Autism. For the purpose of this document the core symptoms of autism are defined as deficits in social communications and social interaction across multiple contexts and restricted, repetitive patterns of behavior, interests, or activities.
    • ABA services in residential facilities to replace or augment the internal behavioral health or ABA program
    • Custodial care with focus on activities of daily living - bathing, dressing, eating and maintaining personal hygiene, etc. - that do not require the special attention of trained/professional ABA staff
    • Any program or service performed in nonconventional settings (even if the services are performed by a licensed provider), including: spas/resorts; academic, vocational or recreational settings; Outward Bound; and wilderness, camp or ranch programs  
 
Excluded Services Definitions:
 
Custodial Care: This is care that does not require access to the full spectrum of services performed by licensed health care professional that is available 24 hours-a-day in facility-based settings to avoid imminent, serious, medical or psychiatric consequences. In determining whether a person is receiving custodial care, we consider the level of care and medical supervision required and furnished, and whether the treatment is designed to improve or maintain the current level of function. We do not base the decision on diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.  
 
By “facility-based,” we mean services provided in a hospital, long-term care facility, extended care facility, skilled nursing facility, residential treatment center (RTC), school, halfway house, group home, or any other facility providing skilled or unskilled treatment or services to individuals whose conditions have been stabilized. Custodial or long-term care can also be provided in the patient’s home, however defined.
 
Custodial or long-term care may include services that a person not medically skilled could perform safely and reasonably with minimal training, or that mainly assist the patient with daily living activities, such as:
 
    • Personal care, including help in walking, getting in and out of bed, bathing, eating (by spoon, tube or gastrostomy), exercising or dressing
    • Homemaking, such as preparing meals or special diets
    • Moving the patient
    • Acting as companion or sitter
    • Supervising medication that can usually be self-administered
    • Treatment or services that any person can perform with minimal instruction, such as recording pulse, temperature and respiration; or administration and monitoring of feeding systems
 
Respite Care: care that provides respite for the individual’s family or persons caring for the individual.
Paraprofessional Care: services provided by unlicensed persons to help maintain behavior programs designed to allow inclusion of members in structured programs or to support independent living goals except as identified in state mandates or benefit provisions.
 
Coding
 
Effective January 1, 2019, there are new CPT category I codes for applied behavioral analysis and are billed in 15 minute units. These services were previously billed with Category III codes in 30 minute or 1 hour units.
 
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
 
Limited to 24 units (6 hours) no more than twice per year.
 
97152-Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes
 
Behavior identification-supporting assessment will require rationale and only face-to-face time by one provider/line therapist is reimbursable.
 
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
 
Maximum units subject to defined limits of the type of ABA service rendered.
 
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
 
Limited to maximum 32 units (8 hours) per week and counts toward the total line therapy as specified per type of ABA service limits [e.g. total for 97153 and 97154 for comprehensive ABA services must not be greater than 160 units (40 hours) per week.]
 
97155-Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes
 
Limited to 32 units (8 hours) per week. [Generally, 4-8 units (1-2 hours) of service per 40 units (10 hours) of direct (line) therapy. The total for 97155 and 97158 must not be greater than 32 units (8 hours) per week.]
 
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
 
Limited to 12 units (3 hours) per week for a maximum of 48 units (12 hours) per month.
 
97157-Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
 
Limited to 12 units (3 hours) per week for a maximum of 48 units (12 hours) per month. [97156 and 97157 must not exceed 12 units (3 hours) per week or 48 units (12 hours) per month.]
 
97158-Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes
 
Limited to 4 units (1 hour) per week.
 
Category III codes will be authorized by New Directions and subject to defined limits of the type of ABA service rendered. The following Category III exposure codes for ABA services were previously billed in 30 minute or 1 hour units and have been modified:
 
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.  
 
 
 
EFFECTIVE PRIOR TO JANUARY 2019
 
Due to the detail of the policy statement, the document containing the coverage statements for dates prior to January 2019 are not online. If you would like a hardcopy print, please email:    codespecificinquiry@arkbluecross.com

Rationale:
A total of fifteen studies were included for review (3 randomized, controlled trials (RCT) and 12 non-randomized, comparative studies) that met selection criteria.  In one of the RCT’s (Sallows and Graupner, 2005), children in both the experimental and control groups improved significantly over time, but there was no statistically significant difference between groups.  Another RTC (Smith, 2000), found significantly better cognitive and communication skills in the experimental group but no difference in adaptive skills. A more comprehensive and better constructed study, the Early Start Denver Model (Dawson et al, 2009) found significant improvement in IQ, language, and adaptive behavior in toddlers (18 to 30 months) who received 20 hours per week of therapy for 2 years compared to a control group of children who received community available therapy.  Diagnostic assignment also improved significantly in the experimental group (29% improved from autistic disorder to PDD), but no significant change in ADOS severity scores.
 
The non-randomized, comparative studies include the seminal study by Lovaas et al (1987; McEachin, 1993).  While these original studies involved a clinic-based ABA therapy program, other studies have compared home-based, community-based, school-based, residential, and outpatient programs.  All of the studies were small, involved children between 15 months to 7 years of age, and utilized IBI at a high level (Lovaas, 40 hours/week of in center, therapist let treatment).  They reported significant improvement in 47% of children with subsequent follow-up (McEachin, 1993) durable improvement sustained for 5 years. This study had a number of serious flaws: small sample size (n=59), no randomization, selection bias (exclusion of low-functioning autistic children), non-standard endpoints, focus on IQ and school placement overlooked other important social and behavioral impairments, and important differences in male:female ratios.  In addition, review has suggested that a select subgroup of children were responsible for the overall changes in the intervention group: the 9 individuals described as “normal functioning” after treatment had a mean IQ gain of 37 points compared to the other 10 members of the intervention group who had a mean gain of only 3 points.  Others note that this degree of improvement has not been replicated in any other subsequent study. Overall this research has been criticized for producing unrealistic expectations about the ability of EIBI to help ASD children attain normal developmental status.
 
In 2004, Shea noted that the results of these early studies have been misstated and misinterpreted by advocates of EIBI and called upon professionals to acknowledge that while EIBI may be beneficial in some ASD individuals, there is no evidence to point to “recovery” or cure. A systematic review by Bassett et al (2000) concluded that while many forms of EIBI benefit ASD, “there is insufficient, scientifically-valid effectiveness evidence to establish a causal relationship between a particular program of intensive, behavioral treatment, and the achievement of ‘normal functioning’.”
 
Within this category, [EIBI] report greater improvements in cognitive performance, language skills, and adaptive behavior skills than broadly defined eclectic treatments available in the community. However, strength of evidence is currently low.  Further, not all children receiving intensive intervention demonstrate rapid gains, and many children continue to display substantial impairment.  Although positive results are reported for the effects of intensive interventions  that use a developmental framework, such as the Early Start Denver Model (ESDM), evidence for this type of intervention is currently insufficient because few studies have been published to date.
 
Less intensive interventions focusing on providing parent training for bolstering social communication skills and managing challenging behaviors have been associated in individual studies with short-term gains in social communication and language use.  The current evidence base for such treatment remains insufficient, with current research lacking consistency in interventions and outcomes assessed.
 
Although all of the studies of social skills interventions reported some positive results, most have not included objective observations of the extent to which improvements in social skills generalize and are maintained within everyday peer interactions.  Strength of evidence is insufficient to assess effects of social skills training on core autism outcomes for older children or play-and interaction-based approaches for younger children.
 
In summary, while there is some evidence to support the premise that EIBI promotes gains in cognitive function, language skills, and adaptive behavior in young children with autism, overall the quality and consistency of results of this research are weak. Weaknesses in research design and analysis coupled with inconsistent results lead to important questions about the benefit of an expensive and intensive intervention.  There is a need for larger, RTC studies to clarify the uncertainty about the effectiveness of EIBI for ASD.  Until better research is completed, EIBI does not meet the Primary Coverage Criteria for evidence of effectiveness.
 
2012 Update
There were no new randomized controlled trials identified in interval literature. The Agency for Healthcare Research and Quality published (AHRQ, 2011) an evaluation of therapies for children with ASD between the ages of 2-12 focusing on treatment outcomes. They noted only 2 RCT’s with only one rated as good quality.  They concluded that: “Some behavioral and educational interventions that vary widely in terms of scope, target, and intensity have demonstrated effects, but the lack of consistent data limits our understanding of whether these interventions are linked to specific clinically meaningful changes in functioning.  The needs for continuing improvements in methodologic rigor in the field and for larger multisite studies of existing interventions are substantial.  Better characterization of children in these studies to target treatment plans is imperative.”  Similarly, a recent Cochrane review (Reichow, 2012) of EIBI for ASD noted: “There is some evidence that EIBI is an effective behavioral treatment for some children with ASD.  However, the current state of the evidence is limited because of the reliance on data from non-randomized studies (CCT’s) due to the lack of RCT’s.  Additional studies using RCT research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD. The following clinical trial was identified from ClinicalTrials.gov: NCT00698997.
 
   

CPT/HCPCS:
0359TBehavior 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
0360TObservational 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
0361TObservational 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 (List separately in addition to code for primary service)
0362TExposure 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
0363TExposure 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 (List separately in addition to code for primary procedure)
0364TAdaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time
0365TAdaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure)
0366TGroup adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time
0367TGroup adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time (List separately in addition to code for primary procedure)
0368TAdaptive 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
0369TAdaptive 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 (List separately in addition to code for primary procedure)
0370TFamily adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)
0371TMultiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)
0372TAdaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients
0373TExposure 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
0374TExposure 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 (List separately in addition to code for primary procedure)
97151Behavior 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
97152Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes
97153Adaptive 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
97154Group 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
97155Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes
97156Family 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
97157Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

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