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).

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.

ABT is used for treatment of Autism Spectrum Disorder (ASD). 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:

• Atypical autism
• Asperger’s disorder
• Childhood autism
• Childhood disintegrative disorder
• Early infantile autism
• High-functioning autism
• Kanner’s autism
• PDD not otherwise specified

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:

• CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies

Clinical Indications

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:

1. A diagnosis of ASD has been made by a licensed medical professional or other qualified health care professional as is consistent with state licensing requirements; and
2. Documentation is provided which describes the person-centered treatment plan that includes all of the following:
   1. Addresses the identified behavioral, psychological, family, and medical concerns; and
   2. Has 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 (Note: this should include, for each goal, baseline measurements, progress to date and anticipated timeline for achievement based on both the initial assessment and subsequent interim assessments over the duration of the intervention); and
   3. Documents that ABT services will be delivered by an appropriate provider who is licensed or certified according to applicable state laws and benefit plan requirements; and
3. Assessments of motor, language, social, and adaptive functions have been completed; and
4. The person-centered ABT treatment plan incorporates goals appropriate for the individual’s age and impairments including social, communication, language skills or adaptive functioning that have been identified as deficient relative to age expected norms with these elements for each target:
   1. Anticipated timeline for achievement of the goal(s), based on both the initial assessment and subsequent interim assessments over the duration of the intervention; and
   2. Family education and training interventions including the behavior parents/caregivers are expected to demonstrate; and
   3. Estimated date of mastery; and
   4. Plan for generalization; and
   5. Discharge or transition planning.

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:

1. Behavior identification assessment: Required prior to beginning a course of ABT. Each request for ABT must include an assessment involving the use of a standardized assessment (for example, Verbal Behavior Milestones Assessment and Placement Program [VB-MAPP], the Vineland Adaptive Behavior Scale [Vineland], the Autism Diagnostic Observation Schedule [ADOS], etc.).
2. Behavior identification supporting assessment
   1. By one technician under the direction of a physician or other qualified health care professional:  May be necessary when one or more non-redirectable disruptive behaviors are present. A request for a behavior identification supporting assessment must provide a description of the disruptive behavior(s) identified. Examples of such behaviors are repetitive gestures or vocalizations, pica, elopement, etc. that are not manageable through redirection techniques.
   2. By a physician or other qualified health care professional present on site and with the assistance of two or more technicians:  May be necessary when one or more non-redirectable disruptive behaviors that pose significant risk of harm to the individual or others are present, and an appropriate intervention has been chosen and planned. The request must include the following: 
      1. of the behavior(s) that pose significant risk of harm to the individual or others; and
      2. of the plan to expose the affected individual to social or environmental stimuli associated with the disruptive behavior; and
      3. of how the assessment will be conducted in a setting conducive to the safety of the individual and other individuals who may be present, including but not limited to, physician, other qualified health care professional, or technician. Examples of such behaviors include repetitive biting, hitting or punching of self or others that are not manageable through redirection techniques.

Notes:
The conduction of the behavior identification assessment and behavior identification supporting assessment together should comprise up to 20 hours of evaluation time. If more than 20 hours of behavior identification assessment and behavior identification supporting assessment together are requested, a rationale must be provided with the request describing the specific situation that warrants additional assessment time.

Repeat behavior identification assessment and behavior identification supporting assessment may be needed when indicated by periodic measurements using standardized assessments. Such repeat assessment should be comprised of fewer than 20 hours in a 6 month interval. More than 20 hours should result in an updated treatment and progress report.

II.  Adaptive Behavioral Treatment (ABT)

Adaptive behavior treatment by protocol 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:

1. The individual has met the criteria above for initial or continuing treatment; and
2. The treatment plan should include treatment with a certified or licensed physician, qualified healthcare provider, or ABT technician (in accordance with state law and benefit plan requirements) for 40 hours per week or less; and
   Note: ABT services for more than 40 hours per week have not been shown to be more effective and documentation as to why more than 40 hours per week is planned must be provided.
3. A certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements) provides protocol modification; and
4. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours requested for each behavioral target. The total hours of ABT requested should be comprised of 40 hours per week or less.

Adaptive behavior treatment with protocol modification:

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:

1. The individual has met the criteria above for an initial course of ABT; and
2. The individual has met the criteria below for ABT with protocol modification; and
3. The professional is an appropriate provider who is licensed or certified according to the requirements of applicable state laws and benefit plan requirements to perform the protocol modification of services; and
4. Up to two (2) hours of protocol modification will be covered for every ten (10) hours of direct ABT therapy. Any greater frequency of protocol modification will require written documentation demonstrating the need for additional protocol modification.

Criteria for adaptive behavior treatment with protocol modification:

1. By a physician or other qualified health care professional present on site which may include simultaneous direction of a technician may be covered when all of the following criteria have been met:
   1. The person-centered treatment plan details the treatment goals for the treatment, describing the type, severity, and frequency of the specific non-redirectable disruptive behaviors; and
   2. The intervention request should specify the services and key functional skills to be included for the target(s); and
   3. The treatment is administered by a certified or licensed physician, qualified healthcare provider, with no more than one technician present; and
   4. The hours of treatment requested should be included in the total hours of ABT requested.
2. By a physician or other qualified health professional present on site and with the assistance of two or more technicians: May be covered when one or more non-redirectable destructive behaviors that pose significant risk of harm to the individual or others are present, and an appropriate intervention has been chosen and planned. The request must include the following: 
   1. of the behavior(s) that pose significant risk of harm to the individual or others; and
   2. of how the plan is to expose the individual to social or environmental stimuli associated with the destructive behavior; and
   3. of how the assessment will be conducted in a setting conducive to the safety of the individual and other individuals who may be present, including but not limited to, physician, other qualified health care professional, or technician.

Note: The total hours of adaptive behavior treatment with protocol modification requested should be comprised of 8 hours or less per week. If additional treatment time is requested a rationale must be provided with the request describing the specific situation that warrants additional time.

Group adaptive behavior treatment by protocol may be covered when all of the following criteria have been met:

1. The person-centered treatment plan addresses specific treatment goals and targeted problem areas; and
2. The goal is to train a group of individuals in the use of behavioral techniques to reduce maladaptive behaviors and increase skill acquisition; and
3. The session is conducted by a certified or licensed physician, qualified healthcare provider, or ABT technician (in accordance with state law and benefit plan requirements); and
4. The individual has sufficient social, language, and adaptive skills to participate in group adaptive behavior treatment; and
5. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours requested for each behavioral target. The total hours of group adaptive behavior treatment requested should be included in the 40 hours per week.

Group adaptive behavior treatment with protocol modification may be covered when all of the following criteria have been met:

1. The person-centered treatment plan addresses specific treatment goals and targeted problem areas; and
2. The goal is to train a group of individuals in the use of social skills to reduce maladaptive behaviors and increase social interactions; and
3. The session is conducted by a certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements); and
4. The individual has sufficient social, language, and adaptive skills for the individual to participate in group adaptive behavior treatment; and
5. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours of social skills group. The total hours of group adaptive behavior treatment requested should be included in the 40 hours per week.

Family adaptive behavior treatment guidance may be covered when all of the following criteria have been met:

1. The goal of the guidance is to provide instruction to a parent, guardian, or other caregiver the treatment protocols to use in reducing the affected individual’s maladaptive behaviors and increase generalization of skills; and
2. The person-centered treatment plan addresses targeted behaviors and specific goals based on assessment of the affected individual; and
3. The scope of the intervention for the targeted behaviors is within the context of management by the family and is such that the guidance may be performed with or without the affected individual present.

Multiple-family group adaptive behavior treatment guidance may be covered when all the following criteria have been met:

1. The person-centered treatment plan addresses specific treatment goals and targeted problem areas; and
2. The goal is to train a group of parents, guardians, or caregivers in the use of behavioral techniques to reduce maladaptive behaviors and skill deficits; and
3. The session is conducted by a certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements); and
4. The intervention is based upon the affected individuals sharing at least one common behavioral target and possible key functional skills that will benefit the individual by group intervention as explained in the clinical summary; and
5. The scope of the intervention for the targeted behaviors is within the context of management by the families and is such that the guidance must be performed in the absence of the affected individual.

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:

1. The individual continues to meet the criteria above for an initial course of ABT; and
2. The person-centered treatment plan will be updated and submitted, in general, every 6 months or as required by a state mandate. Note: Treatment plans may be required more often than every 6 months, for example, when behavior identification supporting assessment or behavioral ABT with protocol modification are required; and
3. The person-centered treatment plan includes age and impairment appropriate goals and measures of progress. The treatment plan should include measures of the progress made with social skills, communication skills, language skills, adaptive functioning, and specific behaviors or deficits targeted. Clinically significant progress in social skills, communication skills, language skills, and adaptive functioning must be documented as follows:
   1. Interim progress assessment at least every 6 months based on clinical progress toward treatment plan goals; and
   2. Developmental status as measured by standardized assessments no less frequent than every 2 years*; and
4. For each goal in the person-centered treatment plan, the following is documented:
   1. Progress-to-date relative to baseline measures is described; and
   2. Anticipated timeline for achievement of the goal(s), based on both the initial assessment and subsequent interim assessments over the duration of the intervention; and
   3. Family education and training interventions including the behavior parents/caregivers are expected to demonstrate and utilize outside the treatment setting (for example, at home or in the community); and
   4. Estimated date of mastery; and
   5. Plan for generalization; and
   6. Transition/fade and discharge planning.

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:

1. The criteria above are not met; or
2. There is no documentation of clinically significant progress in any of the following areas as measured by an interim progress evaluation through standardized assessments:
   1. Adaptive functioning; or
   2. Communication skills; or
   3. Language skills; or  
   4. Social skills.

ABT is considered not medically necessary for all indications other than ASD.

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.

Coding

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.

When services may be covered when criteria are met:
Note: 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.

CPT

When services may be not covered and not medically necessary:
Services may be considered not covered and not medically necessary when the criteria are not met or for situation described in the Clinical Indications section. 

When services are not medically necessary:
For ABT services for all other diagnoses not listed above.

Discussion/General Information

The DSM-5-TR (2022) 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 DSM-5-TR paradigm, are 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 clinical report published by the American Academy of Pediatrics (AAP) (2020) indicated that the prevalence of ASD in the United States is 1 in 59 children.

The specific DSM-5-TR diagnostic criteria for ASD are provided below:

DSM-5-TR Criteria for Autism Spectrum Disorder

Diagnostic criteria

1. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history (examples are illustrative, not exhaustive; see text);
   1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
   2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communications.
   3. Deficits in developing, maintaining and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social context; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
2. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text);
   1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
   2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
   3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
   4. Hyper- or hypoactivity to sensory inputs or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching or objects, visual fascination with lights or movement).
3. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learning strategies in later life).
4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

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 based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2):
Requiring very substantial support
Requiring substantial support
Requiring support
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Specify if:
Associated with a known genetic or other medical condition or environmental factor. (Coding note: Use additional code to identify the associated genetic or other medical condition)
Associated with a neurodevelopmental, mental, or behavioral disorder.
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder, p. 135 for definition). (