Clinical Policy: Applied Behavior Analysis Form

# Clinical Policy: Applied Behavior Analysis
Reference Number: CP.BH.104  
Date of Last Revision: 12/24  

[Coding Implications](#)  
[Revision Log](#)  

See [Important Reminder](#) at the end of this policy for important regulatory and legal information.  

## Description  
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by varying degrees of difficulty in social communication and interaction. ASD is typically a lifelong diagnosis, and the variability of symptom presentation differs for everyone, requiring treatment at any point in time.¹  

Applied Behavioral Analysis (ABA) is the application of behavioral principles to everyday situations, intended to increase skills or decrease targeted behaviors. ABA has been used to improve areas such as language, self-help, and play skills, as well as decrease behaviors such as aggression, self-stimulatory behaviors, and self-injury. Treatment may vary in terms of intensity and duration, complexity, and treatment goals. The extent of treatment provided can be characterized as focused or comprehensive.¹  

Centene will collaborate with providers to implement best practices and standardization of outcome measures into the Applied Behavior Analysis treatment plan.  

## Policy/Criteria  
1. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation® that when a covered benefit, *Applied Behavior Analysis (ABA)* services are **medically necessary** when meeting all the following:  
   A. The member/enrollee has a confirmed autism spectrum disorder (ASD) diagnosis, according to the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria or an appropriate diagnosis as otherwise specified according to state-defined ABA criteria;  
   B. The ASD diagnosis, including severity level, is confirmed by one of the following screening tools:  
      1. Checklist for Autism in Toddlers (CHAT);  
      2. Modified Checklist for Autism in Toddlers/Modified Checklist for Autism in Toddlers, Revised with follow-up (M-CHAT/M-CHAT-R/F);  
      3. Screening Tool for Autism in Toddlers & Young Children (STAT);  
      4. Social Communication Questionnaire (SCQ);  
      5. Autism Spectrum Screening Questionnaire (ASSQ);  
      6. Childhood Autism Spectrum Test, formerly known as the Childhood Asperger’s Syndrome Test (CAST);  
      7. Autism Diagnostic Observation Schedule/Autism Diagnostic Observation Schedule 2nd edition (ADOS/ADOS-2);  
      8. Autism Diagnostic Interview Revised (ADI-R);  
      9. Childhood Autism Rating Scale/ Childhood Autism Rating Scale 2nd edition (CARS/CARS-2);  
      10. Gilliam Autism Rating Scale (GARS-3);  
   11. EarliPoint;  
   12. The Survey of Well-Being of Young Children (SWYC): Parent’s Observations of Social Interactions (POSI);  
   13. Rapid Interactive Screening Test for Autism in Toddlers (RITA-T);  
   14. Communication and Symbolic Behavior Scales Developmental Profile – Infant/Toddler Checklist (CSBS-ITC);  
   15. Other evidence-based assessments, to be reviewed on a case-by-case basis;  
   C. ABA is recommended by a qualified licensed health care provider working within their scope of practice and who is qualified to diagnose ASD;  
   D. A comprehensive diagnostic evaluation, as specified according to state-defined ABA criteria, has been conducted within the past five years and includes a thorough summary demonstrating the effects of current symptoms on the member/enrollee’s functional level in various settings (e.g., family, peer, school), specifically in the areas of communication, socialization, restricted/repetitive patterns of behavior, and adaptive functioning;  
   E. Requested service meets one of the following:  
      1. Behavioral assessment;  
      2. Initiation of ABA treatment, all the following:  
         a. The member/enrollee is medically stable and does not require 24-hour medical/nursing monitoring or procedures provided by a hospital level of care;  
         b. Behavioral assessment has been completed by a Board-Certified Behavior Analyst (BCBA), or other duly certified, licensed, or registered equivalent provider (as defined by state law) and documentation includes all of the following:  
            i. Record review;  
            ii. Interviews;  
            iii. Rating scales;  
            iv. Direct observation and measurement of behavior using one of the following procedures:  
               a) Continuous (records every occurrence and/or duration of a target behavior during each of a series of designated observation periods);  
               b) Discontinuous procedures (divides each designated observation period into a series brief intervals);  
            v. At least one of the following types of assessments depending on the member/enrollee’s noted areas of need:  
               a) For members/enrollees who exhibit problem behaviors that are disruptive and/or dangerous, one of following functional behavioral assessments (FBA):  
                  i) Descriptive FBA (rating scales, direct observation, data review);  
                  ii) Traditional functional analyses;  
                  iii) Interview-Informed, Synthesized Contingency Analysis (IISCA);  
               b) For members/enrollees who demonstrate the need for skill acquisition, one of the following:  
                  i) Verbal Behavior Milestones and Assessment Placement Program (VB-MAPP);  
                  ii) Assessment of Basic Language and Learning Skills-Revised (ABLLSR);  
                  iii) Assessment of Functional Living Skills (AFLS);  
                  iv) Promoting the Emergence of Advanced Knowledge Generalization (PEAK) Skills Assessment;  
                  v) Social Skills Improvement System (SSIS);  
                  vi) Essentials for Living (EFL);  
                  vii) Socially Savvy;  
                  viii) Other valid forms of evidence-based skills assessment tools;  
         c. Individualized treatment plan aligns with the results of the behavior assessment and includes all the following:  
            i. Individualized goals with measurable, targeted outcomes and timelines, including transition/discharge planning, which are identified in collaboration with the member/enrollee, family members and community providers;  
            ii. Interventions focused on active core symptoms and emphasizing generalization and maintenance of skills in areas of need including interventions related to development of spontaneous social communication, adaptive skills, and appropriate behaviors;  
            iii. Parent/Caregiver training that is performance based and caregiver-driven;  
            iv. Treatment setting with rationale for how the setting will maximize treatment outcomes, considering the assessed needs, strengths, and available resources;  
            v. Number of treatment hours meets all of the following:  
               a) Justified by level of impairment, severity of symptoms, length of treatment history, and response to intervention;  
               b) Considers member/enrollee’s age, school attendance requirements, and other daily activities;  
               c) Incorporates supervision and caregiver training;  
               d) Outlines hours of therapy per day with the goal of increasing or decreasing the intensity of therapy as the member/enrollee’s ability to tolerate and participate permits, one of the following:  
                  i) Focused ABA, provided to improve or maintain behaviors in a limited number of domains or skill areas, consists of 10 to 25 hours of direct treatment per week; Comprehensive ABA, provided to improve or maintain behaviors in skill areas across multiple domains, consists of 30 to 40 hours of direct treatment per week;  
            vi. Documentation that ABA treatment will be delivered or supervised by an ABA-credentialed professional and is consistent with ABA techniques. Note: One to two hours of supervision (per 10 hours of direct treatment) is considered standard of care in most cases; two hours of supervision is required if direct treatment totals less than 10 hours per week;  
            vii. Documented coordination of care and communication regarding additional provider responsibilities (i.e., school, prescribers, and physical, occupational and/or speech therapists);  
            viii. Transition planning and discharge considerations made with input from the entire care team and involving a gradual step-down in services;  
      3. Continuation of ABA treatment, all the following:  
         a. Member/enrollee’s behavior concerns are not exacerbated by treatment;  
         b. Member/enrollee has the cognitive ability to retain and generalize advancement in treatment goals;  
         c. Updated behavior assessment is completed every six months (or less, as clinically appropriate, or as state mandated);  
         d. Documented coordination of care and communication regarding additional provider responsibilities (i.e., school, prescribers, and physical, occupational and/or speech therapists);  
         e. Updated treatment plan completed every six months (or less, as clinically appropriate, or as state mandated) and includes all of the following:  
            i. Documentation that ABA treatment will be delivered or supervised by an ABA-credentialed professional and is consistent with ABA techniques.  
               *Note*: One to two hours of supervision (per 10 hours of direct treatment) is considered standard of care in most cases; two hours of supervision is required if direct treatment totals less than 10 hours per week;  
            ii. Qualitative and quantitative data meets all the following:  
               a) Gathered from ABA providers as well as from parents/guardians, teachers, and other caregivers (such as speech therapists, occupational therapists);  
               b) Collected in multiple settings, such as in a clinic, home, and school (as applicable);  
               c) Includes a description of the change over time on all behaviors and skills that are the focus of treatment (includes graphs and data as applicable);  
            iii. Transition planning meets both of the following:  
               a) Transition planning and discharge considerations made with input from the entire care team and involving a gradual step-down in services;  
               b) Discharge criteria has been reviewed and adjusted according to progress and indicates the point at which services are appropriate for discontinuation and/or transfer to alternative or less intensive levels of care;  
         f. There is reasonable expectation that the member/enrollee will benefit from the continuation of ABA services due to one of the following:  
            i. Documented progress toward goals since the last authorization (or an explanation of barriers to progress);  
            ii. Documentation supports that limited progress has been made toward goals since the last authorization, both of the following:  
               a) Updated assessment identifies determining factors that may be contributing to inadequate progress;  
               b) Changes to the treatment plan from the prior authorization period include all of the following:  
                  i) Reevaluation of each treatment plan goal;  
                  ii) Increased time and/or frequency working on targets;  
                  iii) Increased parent/caregiver training and supervision;  
                  iv) Identification and resolution of barriers to treatment effectiveness;  
                  v) Newly identified co-existing conditions, as applicable;  
                  vi) Consideration of alternative treatment settings;  
            vii)Consideration of the effectiveness of ABA. Note: An updated, comprehensive diagnostic evaluation may be warranted to identify if psychological factors other than the autism spectrum disorder are impeding progress;  
            viii) Evaluation for other services that may be helpful for added support including but not limited to, speech therapy, occupational therapy, psychiatric evaluation, psychotherapy, case management, family therapy, feeding therapy, and school-based supports.  

II. It is the policy of Centene Advanced Behavioral Health and affiliated health plans with Centene Corporation that when a covered benefit, Applied Behavior Analysis (ABA) services may be appropriate for **discontinuation and/or transfer to alternative or less intensive levels of care** when meeting any of the following:  
   A. Member/enrollee has achieved the desired socially significant outcomes and treatment is not required to maintain functioning or prevent regression;  
   B. Services are in lieu of school, respite care, or other community-based settings of care;  
   C. There has been no clinically significant progress or measurable improvement towards treatment plan goals for a period of at least six months, and there is not a reasonable expectation that a revised treatment plan could lead to clinically significant progress;  
   D. Treatment or intensity of treatment is being provided for the convenience or preference of the member/enrollee, parent/guardian, or other non-ABA service providers (school or other alternative providers);  
   E. The decision is made by the family or the behavior analyst to end or temporarily suspend services due to (but not limited to) any of the following:  
      1. The parent/caregiver wants to continue the behavior interventions independently;  
      2. The parent/caregiver wants to discontinue services and withdraws consent for treatment;  
      3. The parent/caregiver and provider are unable to reconcile essential issues in treatment planning and delivery;  
      4. The parent/caregiver’s circumstances or interest in treatment change;  
      5. The member/enrollee has transitioned to another provider or community resources for alternative treatment.  

III. It is the policy of Centene Advanced Behavioral Health and affiliated health plans with Centene Corporation that Applied Behavior Analysis (ABA) services are **not covered** for both of the following:  
   A. Services that are otherwise covered under the Individuals with Disabilities Education Act (IDEA).  
      *Note*: Unless restricted within a state Medicaid benefit, ABA services can occur in coordination with school services and transition plans;  
   B. Treatment goals more appropriately conducted in any of the following disciplines:  
      1. Behavioral health outpatient services;  
      2. Speech therapy;  
      3. Occupational therapy;  
      4. Vocational rehabilitation;  
      5. Supportive respite care;  
      6. Recreational therapy;  
      7. Orientation and mobility.  

## Background  
Applied Behavioral Analysis (ABA) is the leading evidenced based, validated treatment for autism spectrum disorder (ASD). It is based on the premise that behavior is determined by past and current environmental events in conjunction with organic variables such as genetic attributes and physiological variables. It focuses on analyzing, designing, implementing, and evaluating social and other environmental modifications to produce meaningful changes in behavior. Services may be provided in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth) to increase adaptive skills and decrease challenging behaviors. ABA includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.¹  

### Council of Autism Service providers (CASP)¹  
The Council of Autism Service Providers (CASP) has developed guidelines and recommendations that reflect established research findings and best clinical practices. There are five core characteristic of applied behavior analysis (ABA) that should be present throughout all phases of assessment and treatment in the form of essential practice elements as follows:  

#  

Services will fall into two treatment models Focused ABA and Comprehensive ABA¹:  
1. **Focused ABA**:  
   Treatment provided directly to the member/enrollee for a limited number of behavioral targets. It is not restricted by age, cognitive level, or co-occurring conditions. Focused ABA treatment may involve increasing socially appropriate behavior (e.g., increasing social initiations) or reducing problem behavior (e.g., aggression) as the primary target. Focused ABA plans are appropriate for individuals who need treatment only for a limited number of key functional skills or have such acute problem behavior that its treatment should be the priority.  

2. **Comprehensive ABA**:  
   Treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypy are also typically the focus of treatment. Intensity levels range from 30-40 hours of treatment per week (plus direct and indirect supervision and caregiver training); however, the intensity of comprehensive treatment must be individualized to the person’s characteristics and other factors.  

### Council of Autism Service Providers (CASP) Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis²  
Due to a shortage of providers and disparities which exist in behavioral health care access, telehealth services have become a viable solution to address health access to treat members/enrollees with ASD. This service is not intended to replace in person service, as it is intended to supplement the traditional in person service delivery model.³ Clinical decisions on telehealth service delivery models should be selected based on the individual needs, strengths, preference of service modality, caregiver availability and environmental support available. Providers should refer to respective state allowances for telehealth services and reference the most updated CASP Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis.  

## American Academy of Pediatrics (AAP)³  
The AAP recommends that all children be screened for ASD at ages 18 and 24 months, along with regular developmental surveillance. Toddlers and children should be referred for diagnostic evaluation when increased risk for developmental disorders (including ASD) is identified through screening and/or surveillance. Although symptoms of ASD are neurologically based, they manifest as behavioral characteristics that present differently depending on age, language level, and cognitive abilities. Core symptoms cluster in 2 domains (social communication, interaction, and restricted, repetitive patterns of behaviors), as described in the DSM-5-TR.  

### The Diagnostic and Statistical Manual of Mental Disorder, Fifth edition (DSM-5-TR)⁴  
The Diagnostic and Statistical Manual of Mental Disorder, list the following as the severity levels for autism spectrum disorders: They are divided into two domains (social communication and social interaction and restrictive, repetitive patterns of behaviors) To fulfill diagnostic criteria for ASD by using the DSM-5 TR, all 3 symptoms of social affective difference need to be present in addition to 2 of 4 symptoms related to restrictive and repetitive behaviors.  

| Severity Level | Social Communication | Restricted, repetitive behaviors |
|----------------|---------------------|----------------------------------|
| **Level 3 “Requiring very substantial support”** | Severe deficits in verbal and nonverbal social communication 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/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 changes focus or action. |
| **Level 2 “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 interest, 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. |
| **Level 1 “Requiring support”** | 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 can speak in full sentences and engages in communication but who is to and from conversation with others fails, and who 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. |

## Coding Implications