Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|05|2024 POLICY LAST REVIEWED: 02|07|2024 OVERVIEW Applied Behavioral Analysis (ABA) is the process of systematically applying interventions based on learning theory and using them to improve socially important behaviors to a meaningful degree and to demonstrate that the interventions employed are responsible for the improvement. It is often used to treat children with Autism Spectrum Disorders (ASD) or other Pervasive Development Disorders (PDDs). It involves the design, implementation, and evaluation of behavioral modification plans for the purpose of producing significant improvement in the identified behavior. With this type of treatment, problematic behaviors, the events leading up to them, and the consequences of those behaviors are identified. Intensive behavioral intervention therapy involves highly structured techniques that are delivered by a therapist on a one-to-one basis. The objectives of treatment are to improve the child's social communication and interaction skills, leading to the potential development of play and flexibility of behavior. The targeted behaviors addressed by behavioral analysis are often referred to as challenging behaviors. These behaviors may be due to the following: environmental factors, physical conditions, mental health disorders, adaptive functioning, and psychological factors. The severity and frequency of these behaviors may result in risk to the physical safety of the individual or others. These behaviors include, but are not limited to, aggression, violence, destructiveness, and self-injury. General behavioral goals of ABA include: teaching new skills, increasing selected behaviors, maintaining selected behaviors, generalizing or transferring selected behaviors, restricting or narrowing conditions under which interfering behaviors occur, and reducing interfering behaviors. Socially significant behaviors that are frequently targeted for maintaining or increasing to a meaningful degree include: reading, academics, social skills, communication, and adaptive living skills (e.g., gross and fine motor skills, eating and food preparation, toileting, dressing, personal self-care, domestic skills, time and punctuality, money and value, home and community orientation, and work skills). This policy is applicable to Commercial Products only.
MEDICAL CRITERIA
Not applicable NOTIFICATION OF ADMISSION Not applicable POLICY STATEMENT Commercial Products Coverage is provided for the following services for the treatment of Autism Spectrum Disorders (ASD), as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM): ABA services, pharmaceuticals, physical therapy, speech therapy, psychology, psychiatric, and occupational therapy services (“Autism Services”). The following limits apply:
• ABA services are provided and/or supervised by an individual licensed by the state in which the service is rendered: a. A Licensed Applied Behavior Analyst; or Payment Policy | Autism Spectrum Disorders Mandate

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

b. A Licensed Applied Behavior Assistant Analyst under the supervision of a Licensed Applied Behavior Analyst; or c. A psychologist with equivalent experience as an Applied Behavior Analyst or a psychologist practicing within their scope of practice.

For benefit plans that do not provide coverage for Autism Services or are not subject to the Rhode Island Autism Spectrum Disorders Mandate and for self-insured or self-funded groups that have opted NOT to adopt the Rhode Island Autism Spectrum Disorders Mandate, behavioral interventions based on the principles of Applied Behavioral Analysis (ABA and related programs for the treatment of PDDs/ASDs) are a contract exclusion for some members. Please refer to the specific member agreements.

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy for Autism Spectrum Disorders (excluding ABA services)
For any group that offers Autism Services, PT/OT and speech therapy services are covered and excluded from any service limits or preauthorization requirements.

If a speech language therapist/physical therapist/occupational therapist is certified as an ABA provider and renders ABA services, they must use the specific ABA codes in the coding section of this policy to report these services.

This coverage of Autism Services does not affect any obligation of a school district or government entity to provide services to an individual under an individualized family service plan or an individualized education program, as required by federal or state law. This means that, for services related to ASD, no benefits are provided for services that are furnished by school personnel.

For more information, please contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable service benefits/coverage.

BACKGROUND As of January 1, 2012, BCBSRI began to provide coverage for Autism Services for all large employer groups in compliance with the state law mandating coverage for ASD, R.I. General Law 27-20.11-1. Self-funded accounts had the option to elect or decline coverage of Autism Services.
Mandatory coverage for ASD is defined per R.I. General Law 27-20.11-2 as follows:

27-20.11-1. Mandatory coverage for Autism Spectrum Disorders.
(a) Every group health insurance contract, or every group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state, by any health insurance carrier, on or after January 1, 2012, shall provide coverage for Autism Spectrum Disorders; provided, however, the provisions of this chapter shall not apply to contracts, plans or group policies subject to the Small Employer Health Insurance Availability Act, chapter 50 of this title, or subject to the Individual Health Insurance Coverage Act, chapter 18.5 of this title.

27-20.11-2. Definitions. As used in this chapter: (1) “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvements in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

(2) “Autism Spectrum Disorders” means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. (3)"Health insurance carrier" or "carrier" means any entity subject to the insurance laws and regulations of this state, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including, without limitation, an insurance company offering accident and sickness insurance, a health maintenance organization, a nonprofit hospital, medical service corporation, or any other entity subject to chapter 18, 19, 20, or 41 of this title, providing a plan of health insurance, health benefits, or health services.

27-20.11-3. Scope of coverage. (a) Benefits under this section shall include coverage for applied behavior analysis, physical therapy, speech therapy and occupational therapy services for the treatment of Autism Spectrum Disorders, as defined in the most recent edition of the DSM. Provided, however: (1) Coverage for physical therapy, speech therapy, and occupational therapy services shall be to the extent such services are a covered benefit for other diseases and conditions under such policy; and (2) Applied Behavior Analysis. (b) Benefits under this section shall continue until the covered individual reaches age fifteen (15). (c) The health care benefits outlined in this chapter apply only to services delivered within the State of Rhode Island; provided, that all health insurance carriers shall be required to provide coverage for those benefits mandated by this chapter outside of the State of Rhode Island where it can be established through a preauthorization process that the required services are not available in the State of Rhode Island from a provider in the health insurance carrier’s network.

• Note: BCBSRI does not have any age restrictions for Autism Services

  27-20.11-4. Medical necessity and appropriateness of treatment.
  (a) Upon request of the reimbursing health insurance carrier, all providers shall furnish medical records or other necessary data, which substantiates that initial or continued treatment is at all times medically necessary and appropriate. (b) Medical necessity criteria may be based in part on evidence of continued improvement as a result of treatment. When the provider cannot establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care that was not established. The exception to the preceding can only be made if the patient has been informed of the provisions of this subsection and has agreed in writing to continue to receive treatment at his or her own expense. (c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter may appeal a denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23. (d) A health insurance carrier may require submission of a treatment plan, including the frequency and duration of treatment, signed by a child psychiatrist, a behavioral developmental pediatrician, a child neurologist, or a licensed psychologist with training in child psychology, that the treatment is medically necessary for the patient and is consistent with nationally recognized treatment standards for the condition such as those set forth by the American Academy of Pediatrics. An insurer may require an updated treatment plan no more frequently than on a quarterly basis.

  27-20.11-5. Limits on cost sharing. Benefits for services under this chapter shall be reimbursed in accordance with the respective principles and mechanisms of reimbursement for each health insurance carrier. Except as otherwise provided in this section, any policy, contract or certificate that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are no more extensive than coverage provided for other conditions or
  illnesses. Coverage for Autism Spectrum Disorders is otherwise subject to the same terms and conditions of the policy as any other condition or illness.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

27-20.11-6. Educational and other services provided to children diagnosed with Autism Spectrum Disorders.
Nothing in this section shall be construed to alter any obligation of a school district or the State of Rhode Island to provide services to an individual under an individualized family service plan or an individualized education program, as required under the federal Individuals with Disabilities Education Act, or the provision of services to an individual under any other federal or state law. A health insurance carrier assessed for services provided under section 42-12-29, children’s health account, shall not be required to provide duplicative coverage for the same beneficiary for the same or similar services mandated under this section.

27-20.11-7. Credentials.
(a) Any individual providing applied behavior analysis treatment under this section shall be: (1) Individually licensed by the department of health as a health care provider/clinician pursuant to chapter 42-35 or 42-35-1 et al. and nationally certified as a Board-Certified Behavior Analyst (BCBA); and credentialed by the insurer; or (2) Individually nationally certified as a Board-Certified Assistant Behavior Analyst (BCaBA) supervised by a Board-Certified Behavior Analyst who is licensed by the department of health as a psychologist, social worker or therapist; and credentialed by the insurer. (b) Nothing in this chapter shall be construed to require a change in the credentialing or contracting practices of health insurers for mental health or substance abuse providers

27-20.11-8 Exclusions. This chapter shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited benefit policies.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits. As a result of this act, as well as the prohibition on dollar limits under the Affordable Care Act, the dollar limits in the state mandate are not applicable. Additionally, the visit limits applicable to physical therapy, occupational therapy, and speech therapy when covered for reasons other than as treatment for ASD, do not apply when provided as treatment for ASD.

CODING Commercial Products
The following code(s), when rendered by a certified ABA provider, are covered when medically necessary: 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. 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

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

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 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 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 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 97155 Adaptive behavior treatment with protocol modification, administered by a physician or other qualified health care professional, which may include simultaneous direction of technician, face-to- face with one patient, each 15 minutes 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 97157 Multiple-family group adaptive behavior treatment guidance, administered by a physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes 97158 Group adaptive behavior treatment with protocol modification, administered by a physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

The following CPT code(s) are NOT to be used and providers should file with the applicable Category I and III codes above: H0031-32 Mental health assessment, by non-physician for the certified ABA professional to create a treatment plan: H0032-32 Mental health service plan development by non-physician H2019-32 Therapeutic behavioral services, per 15 minutes H2012-32 Behavioral health day treatment, per hour H2014-32 Skills training and development, per 15 minutes

Physical Therapy, Occupational Therapy, Speech Therapy The following code(s), when submitted with a PRIMARY diagnosis of Autism (F84.0, F84.5, F84.8 and F84.9), are covered and excluded from any service limits or prior authorization requirements: 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); group, two or more individuals 92526 Treatment of swallowing dysfunction and/or oral function for feeding 92609 Therapeutic services for the use of speech-generating device, including programming and modification 97127 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact
97129 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes- New Effective 1/1/2020 97161 Physical therapy evaluation: low complexity 91662 Physical therapy evaluation: moderate complexity 97163 Physical therapy evaluation: high complexity

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

97164 Re-evaluation of physical therapy (this code is not separately reimbursed)
97165 Occupational therapy evaluation, low complexity 97166 Occupational therapy evaluation, moderate complexity 97167 Occupational therapy evaluation, high complexity 97168 Re-evaluation of occupational therapy this code is not separately reimbursed)
97012 Application of a modality to 1 or more areas; traction, mechanical 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended) 97016 Application of a modality to 1 or more areas; vasopneumatic devices 97018 Application of a modality to 1 or more areas; paraffin bath 97022 Application of a modality to 1 or more areas; whirlpool 97024 Application of a modality to 1 or more areas; diathermy (e.g., microwave) 97026 Application of a modality to 1 or more areas; infrared 97028 Application of a modality to 1 or more areas; ultraviolet 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes 97033 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes 97034 Application of a modality to 1 or more areas; contrast baths, each 15 minutes 97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) 97139 Unlisted therapeutic procedure (specify) 97140 Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes 97150 Therapeutic procedure(s), group (2 or more individuals) 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes 97535 Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes 97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes

RELATED POLICIES Speech Therapy Physical and Occupational Therapy
Unlisted Procedures

PUBLISHED Provider Update, February 2024 Provider Update, February/December 2023 Provider Update, January 2021 Provider Update, January/November 2020

REFERENCES

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 7 (401) 274-4848 WWW.BCBSRI.COM

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (5th ed., DSM-5). Washington, D.C.
2. Behavior Analyst Certification Board, Inc. (2012). Guidelines: Health plan coverage of applied behavior analysis treatment for Autism Spectrum Disorder. Tallahassee, FL.
3. Eikeseth S. Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities. 2009;30:158-78.
4. Matson JL, et al. Issues in the management of challenging behaviors of adults with Autism Spectrum Disorder. CNS Drugs 2011;25(7):597-606.
5. McEachin JJ, et al. Long-term outcome for children with autism who received early intensive behavioral treatment. Amer J Mental Retardation. 1993;97(4):359-91.
6. Kovshoff H, et al. Two-year outcomes for children with autism after the cessation of early intensive behavioral intervention. Behavior Modification 2011;35:427-50.
7. Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consulting Clinical Psychology 1987;55:3-9.
8. Virues-Ortega J. Applied behavior analytic intervention for Autism in early childhood: meta-analysis, meta- regression and dose-response meta-analysis of multiple outcomes. Clinical Psychology Review 2010;30:387-99. *Volkmar F, et al. Summary of the practice parameters for the assessment and treatment of children, adolescents and adults with autism and other pervasive developmental disorders. Amer Acad Child Adolescent Psychiatry 1999;38(12):1611-6.
9. http://www.dol.gov/ebsa/mentalhealthparity/

10. Rhode Island General Law (RIGL) Mandate http://webserver.rilin.state.ri.us/Statutes/TITLE27/27- 20.11/INDEX.HTMi

    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS