Clinical Policy: Applied Behavior Analysis

Reference Number: CP.BH.104 Date of Last Revision: 09/25

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

See [Important Reminder](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.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 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 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 and documentation of all the following:
   1. The documented diagnosis of ASD is established by a licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law to diagnose autism;
   2. Severity level (requires support, requires substantial support, or requires very substantial support);
   3. With or without accompanying intellectual impairment;
   4. With or without accompanying language impairment;
   5. Associated with a known medical or genetic condition or environmental factor; B. A comprehensive diagnostic evaluation, as specified according to state-defined ABA criteria, includes a thorough summary demonstrating the effects of current symptoms on the member/enrollee’s functional level in various settings (e.g., with family and/or peers in home, school, and community), specifically in the areas of communication, socialization, restricted/repetitive patterns of behavior, and adaptive functioning and meets all the following (1-3):
   6. One of the following: a. Treatment initiation, one of the following: i. CDE has been conducted in the past three years; ii. A diagnostic interview/evaluation has been conducted within 12 months of the authorization request if the CDE was conducted more than three years ago and less than five years ago, meeting all the following: a) Reason member/enrollee is seeking services; b) Comprehensive mental status exam that supports the treatment; c) DSM diagnosis (current version), including recommendations for active treatment interventions; d) History & symptomology consistent with DSM (current version) criteria; e) Psychiatric treatment history; f) Assessment of current and past suicide/homicide danger; g) Level of familial support assessed and involved as indicated; h) Identified areas for improvement; i) Assessment of strengths, skills, abilities, motivation; j) Medical history; k) All current medications with dosages; b. Treatment continuation: CDE has been conducted within the past five years; Note: A diagnostic re-evaluation to re-confirm diagnosis may be required sooner than every five years for any of the following:
      • A provisional diagnosis of ASD;
      • No formal psychological or neuropsychological evaluation was completed or conducted;
      • To identify if psychological factors other than the ASD are impeding progress;
      • During times of transition, or when more than three years have passed since the initial diagnosis and there is no evidence of ongoing assessment and treatment.
   7. Documents all of the following: a. Direct observation; b. Parent/caregiver interview; c. Results of the evaluation in report format, including all the following: i. Developmental history; ii. Presenting concerns; iii. Summary of each individual assessment/evaluation instrument; iv. Test administered with scores and date completed; v. Evaluator’s name, signature, and credentials; vi. A minimum of two of the following assessment tools, including at least one primary clinician tool: a) Primary clinician tool, at least one of the following: i) Screening Tool for Autism in Toddlers & Young Children (STAT); ii) Autism Diagnostic Interview Revised (ADI-R); iii) Childhood Autism Rating Scale/ Childhood Autism Rating Scale 2nd edition (CARS/CARS-2); iv) Gilliam Autism Rating Scale (GARS-3); v) Autism Diagnostic Observation Schedule/Autism Diagnostic Observation Schedule 2nd edition (ADOS/ADOS-2); b) Parent or caregiver tool: i) Checklist for Autism in Toddlers (CHAT); ii) Modified Checklist for Autism in Toddlers/Modified Checklist for Autism in Toddlers, Revised with follow-up (M-CHAT/M-CHAT- R/F); iii) Social Communication Questionnaire (SCQ); iv) Autism Spectrum Screening Questionnaire (ASSQ); v) Autism Spectrum Test, formerly known as the Childhood Asperger’s Syndrome Test (CAST); vi) Gilliam Autism Rating Scale (GARS-3); vii) The Survey of Well-Being of Young Children (SWYC): Parent’s Observations of Social Interactions (POSI); viii) Communication and Symbolic Behavior Scales Developmental Profile – Infant/Toddler Checklist (CSBS DP-ITC); ix) Other evidence-based assessments, to be reviewed on a case-by-case basis;
   8. Physical health concerns have been evaluated and ruled out as causal reasons for behavior (i.e., medical concerns, speech deficits, hearing deficits, heavy metal poisoning); C. Recommendation for ABA meets both of the following:
   9. Made based on the member/enrollee’s presenting symptoms by a licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law to diagnose autism; Note: This recommendation may be included within the CDE.
   10. Required when an initial or updated CDE is required, per criteria in I.B.1.; D. All treatment plan documents (treatment plan, goals, and behavior intervention plan, if submitted separately) include the HIPPA-compliant signature, credentials, and role of the BCBA/BCBA-D responsible for the member’s care, the member’s parent or legal guardian, and any additional person who reviewed and signed the plan; E. Requested service meets one of the following:
   11. Behavioral assessment;
   12. 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 in a hospital level of care; b. Behavioral assessment completed no more than two months prior to the start of the initial treatment authorization, includes all the following: i. Completed by a Board-Certified Behavior Analyst (BCBA), or other duly certified, licensed, or registered equivalent provider (as defined by state law); ii. Record review; iii. Interviews; iv. Rating scales; v. 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 of brief intervals); vi. Results from at least one of the following types of assessments (to include visual representations [graphs, tables, grids] as appropriate), depending on the member/enrollee’s noted areas of need: a) Maladaptive behavior assessments for members/enrollees who exhibit problem behaviors that are disruptive and/or dangerous, including but not limited to, 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) Skills acquisition assessments, for members/enrollees who demonstrate the need for skill acquisition, including but not limited to 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) Essentials for Living (EFL); vi) Social Skills Improvement System (SSIS); vii) Socially Savvy; viii) Other valid forms of evidence-based skills assessment tools; Note: If the Vineland Adaptive Behavior Scales is used as a skills assessment, an additional, direct skills assessment is required from the list above. c. Individualized treatment plan aligns with the results of the behavior assessment, and includes all the following: i. A brief background and medical history; ii. Explicit goals with measurable, targeted outcomes and timelines, including transition/discharge planning, including all the following: a) Identified in collaboration with the member/enrollee, family members and community providers; b) Skill acquisition goals including baseline data and mastery criteria; c) Behavior reduction goals including baseline data, operational definition/topography of behavior, treatment strategies and graphs; d) 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; iv. A dedicated crisis plan; v. Detailed school-based plan requirements, as applicable, include all the following: a) Documentation of hours of treatment provided; b) Target behaviors that are operationally defined with measurable data regarding the frequency, symptom intensity, duration or other objective measures of baseline and current levels; c) Days and times when problem behaviors occur at a high frequency, intensity, and/or duration; d) Outline of goals related to behavior reduction and skill acquisition that represent desirable behaviors and achieve the same outcome or meet the same need as a less desirable problem behavior; e) Titration plan outlines when school services can be reduced or stopped, based on a timeline with clear progress criteria; f) Behavior reduction graphs tailored for the school setting; Note: The most recent school-based educational support plan may be shared as supporting documentation for members/enrollees who attend school; vi. Treatment setting with rationale for how the setting will maximize treatment outcomes, considering the assessed needs, strengths, and available resources; vii. Number of treatment hours meets all the following: a) Justified by level of impairment, severity of symptoms, domains requiring treatment, length of treatment history, and response to intervention; b) Considers member/enrollee’s age, school attendance requirements, and other daily activities (i.e., less than 20 hours per week if attending school full-time); 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 and all of the following: i) Treatment hours provided to the member/enrollee meet one of the following: 1) Do not exceed six hours per day up to a total of 30 hours per week; 2) Clinical documentation justifies additional hours beyond six hours per day or a total of 30 hours per week, ( i.e. member/enrollee exhibits high intensity, high frequency behaviors, and/or significant skill deficits); ii) Treatment takes into consideration the developmental level of each member/enrollee, and treatment schedules support their needs, including rest and nutrition breaks, as well as opportunities for peer interaction; viii. Documentation that ABA treatment will be delivered or supervised by an ABA-credentialed professional and is consistent with ABA techniques; ix. Adaptive Behavior Treatment with Protocol Modification occurs for at least two hours per week or 10% of the direct service hours provided, whichever is greater; Note: One to two hours per week for less than 10 hours per week is acceptable; x. Coordination of care includes both of the following, as applicable: a) Identifies each alternative provider who is responsible for delivering services; b) Documentation of dates and outcomes from coordination of care efforts; xi. Parent/Caregiver training that is performance based and caregiver-driven, including all the following: a) Goals for family involvement within the treatment plan including baseline data and mastery criteria; b) A documented plan for parent/caregiver training, ideally for a minimum of two hours per month, with clinical documentation justifying the need for fewer hours; c) An assessment for barriers to family engagement, and documented plan for addressing barriers; Note: Inability to meet this requirement must be documented and will be considered on a case-by-case basis. xii. Transition planning, including discharge considerations made with input from the caregiver and entire care team, involving a gradual step-down in services and a documented titration plan including all the following: a) Specific titration goals and plan indicating how service hours will be titrated; b) Individualized, realistic/attainable, and specific goals for discharge and/or transfer to alternative or less intensive levels of care; c) Recommended services member/enrollee can access upon discharge;
   13. 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 at least every six months (or as clinically appropriate, or as state mandated) and meets criteria I.E.2.b.; d. Documentation of percentage of scheduled sessions successfully completed for the member/enrollee and caregiver participation; Note: If attendance falls below 80% of the authorized hours within an authorization period, as specified in the individualized treatment plan and caregiver training plan, supporting documentation is required to justify continuation of ABA services at the previously approved level. When absences are attributed to medical, educational, or family barriers, documentation must also demonstrate the actions taken to address such barriers. e. Parent/Caregiver training that is performance-based and caregiver-driven, including all the following: i. Goals for family involvement within the treatment plan including baseline data and mastery criteria; ii. Documented family participation in treatment, ideally for two hours per month at minimum, or there are documented attempts to engage caregivers, unless clinical documentation supports the need for fewer hours; iii. An assessment for barriers to family engagement, and documented plan for addressing barriers; f. Documented coordination of care and communication regarding additional provider responsibilities (i.e., school, prescribers, and physical, occupational and/or speech therapists) and including all the following: i. Individualized expectations, prescribed services, service frequency, scope and duration, and goals to be achieved; ii. Progress related to treatment/services provided; iii. Documentation of coordination attempts if unsuccessful; g. Updated treatment plan completed at least every six months (or as clinically appropriate, or as state mandated) and meets criteria I.E.2.i.-x. and transition planning meets all the following: i. Transition planning and discharge considerations made with input from the entire care team and involving a gradual step-down in services; ii. Documented titration plan includes the following: a) Specific titration goals and plan indicating how service hours will be titrated; b) Individualized, realistic/attainable and specific goals for discharge and/or transfer to alternative or less intensive levels of care; c) Updated progress towards goals achieved over the prior authorization period; d) Recommended services member/enrollee can access upon discharge; h. There is reasonable expectation that the member/enrollee will benefit from the continuation of ABA services; i. Documented progress toward goals since the last authorization including all the following: i. Updated data collected during previous treatment authorization, corresponding to all treatment settings, including but not limited to, home, school, clinic, community setting, etc.; ii. Progress with behavior reduction, as applicable, noted in a clear and legible graphic display, including: clear labels on each axis with indicators of treatment changes and environmental variables that could effect change, baseline data, behavior reduction progress over time, and frequency and/or duration of behaviors; iii. Progress with skill acquisition goals including baseline data and updated progress data for each treatment goal; j. If limited progress, both of the following: Note: Limited progress is defined as minimal to no improvement toward: mastery of treatment goals, improvement in meaningful skills of independence and self- care, improved scores on direct skills assessments and/or minimal reduction in behaviors targeted for reduction. i. Updated assessment identifies determining factors that may be contributing to inadequate progress; ii. Changes to the treatment plan from the prior authorization period may include the following, as applicable: a) Modification of treatment plan goals and intervention strategies; b) Increased time and/or frequency working on targets; c) Increased parent/caregiver training and supervision; d) Increased staff supervision and training; e) Identification and resolution of barriers to treatment implementation; f) Newly identified co-existing conditions, as applicable; g) Consideration of alternative treatment settings; h) Consideration of the effectiveness of ABA; i) 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 health plans affiliated 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, such as, but not limited to, the following:
   14. A consistent lack of change in behavior reduction and skill acquisition data;
   15. An increase in behaviors targeted for reduction;
   16. Failure to meet predefined mastery criteria for a specified duration;
   17. ABA treatment plan gains are not generalizable or durable over time and do not transfer to the larger community setting after successive progress review periods and repeated modifications to the treatment plan; 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:
   18. The parent/caregiver can continue the behavior interventions independently;
   19. 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; F. The member/enrollee has transitioned to another provider or community resources for alternative treatment. III. It is the policy of health plans affiliated with Centene Corporation that Applied Behavior Analysis (ABA) services are not medically necessary for any 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:
   20. Behavioral health outpatient services;
   21. Speech therapy;
   22. Occupational therapy;
   23. Vocational rehabilitation;
   24. Supportive respite care;
   25. Recreational therapy;
   26. Physical therapy.

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

In 2025, the National Academies of Sciences, Engineering, and Medicine conducted a comprehensive autism care demonstration report for military families. The report concluded that the intensity of ABA services should be individualized, based on the needs of the person with autism, the priorities of their family, and the expertise of the professional’s providing services.

The committee did not endorse a uniform recommendation that all individuals with autism receive the same intensity (e.g., 30–40 hours per week). Instead, the number of weekly hours of direct ABA services required to support meaningful health outcomes should be determined by a qualified behavior analyst, taking into consideration the following:

1. The number and type of goals targeted in treatment.
2. Other services the client receives.
3. The client’s learning rate.
4. Input from the client and their family.

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 characteristics 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:

Core characteristics of ABA treatment

1. An objective assessment and analysis of the person’s condition by observing how the environment affects their behavior, as evidenced through appropriate measurement.
2. Understanding the context of the behavior and the behavior’s value to the person, their caregivers, their family, and the community.
3. Promotion of the person’s dignity.
4. Utilization of the principles and procedures of behavior analysis to improve the person’s health, skills, independence, quality of life and autonomy.
5. Consistent, ongoing, objective data analysis to inform clinical decision making.

Essential practice elements:

1. A comprehensive assessment that describes specific levels of behavior(s) at baseline and informs the subsequent establishment of meaningful treatment goals.
2. An emphasis on understanding the current and future value or social importance of behavior(s) targeted for treatment.
3. Reasonable efforts toward collaboration with the person receiving treatment, their guardians if applicable, and those who support them (e.g., caregivers, care team) in developing meaningful treatment goals.
4. A practical focus on establishing small units of behavior that build toward larger, more significant changes in abilities related to improved health, safety, skill acquisition, and/or levels of independence and autonomy.
5. Collection, quantification, and analysis of direct observational data on behavioral targets during treatment and follow-up to maximize and maintain progress toward treatment goals.
6. Design and management of social and learning environment(s) to minimize challenging behavior(s) and maximize the rate of progress toward all goals.
7. An approach to the treatment of challenging behavior that links the function(s) of, or the reason(s) for, the behavior with programmed intervention strategies.
8. Use of a carefully constructed, individualized, and detailed behavior-analytic treatment plan that utilizes reinforcement and other behavioral principles and excludes methods or techniques not based on established behavioral principles and theory.
9. Use of treatment protocols that are implemented repeatedly, frequently, and consistently across environments until discharge criteria are met.
10. An emphasis on frequent, ongoing analysis and adjustments to the treatment plan based on patient progress.
11. Direct training of caregivers and other involved laypersons and professionals, as appropriate, to support increased abilities and generalization and maintenance of behavioral improvements.
12. A comprehensive infrastructure for case supervision by a behavior analyst of all assessments and treatment.

CLINICAL POLICY Applied Behavior Analysis

Council of Autism Service Providers (CASP) Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis³
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)⁴
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 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 behavior), as described in the DSM-5-TR.

The Diagnostic and Statistical Manual of Mental Disorder, Fifth edition (DSM-5-TR)⁵
The Diagnostic and Statistical Manual of Mental Disorder lists 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.

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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. | Difficulty switching between activities. Problems of organization and planning hamper independence.

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. The inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance and applicable state guidance, prior to the submission of claims for reimbursement of covered services.

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2. National Academies of Sciences, Engineering, and Medicine. The Comprehensive Autism Care Demonstration: Solutions for Military Families. Washington, DC: National Academies Press. https://doi.org/10.17226/29139. Accessed September 25, 2025.
3. The Council of Autism Service Providers. Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis: Second Edition.https://www.casproviders.org/practice-parameters-for-telehealth/. Updated December 1, 2021. Accessed September 25, 2025.
4. American Academy of Pediatrics: AAP Recommendations. https://www.aap.org/en/patient-care/autism/. Website Accessed September 25, 2025.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. https://doi.org/10.1176/appi.books.9780890425787. Published March 8,2022. Accessed September 25, 2025.
6. Reichow B, Hume K, Bartone EE, Boyd BA. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2018;5(5):CD009260. Published 2018 May 9. doi:10.1002/14651858.CD009260.pub3. Accessed September 25, 2025.
7. Georgia Department of Community Health Division of Medicaid. Part II Policies and Procedures for Autism Spectrum Disorder (ASD) Services. https://www.mmis.georgia.gov/portal/PubAccess. Published July 1, 2025. Accessed September 25, 2025.
8. Nebraska Department of Health and Human Services. Medicaid Behavior Health Definitions. https://dhhs.ne.gov/Pages/Medicaid-Behavioral-Health-Definitions.aspx. Published February 10, 2025. Accessed September 25, 2025.
9. Texas Health and Human Services Commission. (2025). Texas Medicaid Provider Procedures Manual: Vol. 2. TMHP. https://www.tmhp.com/resources/provider-manuals/tmppm. Published August 29, 2025. Accessed September 25, 2025.
10. Oklahoma Secretary of State Administrative Rules. Title 317. Oklahoma Health Care Authority. Chapter 30. Part 30. Applied Behavior Analysis (ABA) Services. OAC 317:30-5-310 through 317:30-5-316. https://oklahoma.gov/oha/policies-and-rules/xpolicy/medical-providers-fee-for-service/individual-providers-and-specialties/applied-behavior-analysis-services.html. Updated September 1, 2025. Accessed September 25, 2025.
11. South Carolina Department of Health and Human Services. Autism Spectrum Disorder (ASD) Services Provider Manual. https://www.scdhhs.gov/providers/manuals/autism-spectrum-disorder-asd-services-manual. Updated September 1, 2025. Accessed September 25, 2025.
12. Augustyn M, Hahn LE, Autism spectrum disorder in children and adolescents: Evaluation and diagnosis. UpToDate. https://www.uptodate.com. Updated September 4, 2025. Accessed September 25, 2025.
13. Weismann, L. Autism spectrum disorder in children and adolescents: Screening tools. UpToDate. https://www.uptodate.com. Updated August 14, 2025. Accessed September 25, 2025.
14. Weismann, L. Autism spectrum disorder in children and adolescents: Behavioral and educational interventions. UpToDate. https://www.uptodate.com. Updated June 19, 2025. Accessed September 25, 2025.
15. Health Technology Assessment. Comparative Effectiveness Review of Intensive Behavioral Intervention for Treatment of Autism Spectrum Disorder. Hayes. www.hayesinc.com. Published March 13, 2019 (annual review February 10, 2022). Accessed September 25, 2025.
16. Health Technology Assessment. EarliPoint (EarliTec Diagnostics Inc.) as an Aid in Diagnosis of Autism Spectrum Disorder in Children. Hayes. www.hayesinc.com. Published April 3, 2024. Accessed September 25, 2025.

Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

©2009 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation.

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