Cigna Intensive Behavioral Interventions - (EN0499) Form

Coverage Policies are intended to provide guidance in interpreting benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment where appropriate and have discretion in making individual coverage determinations. Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s). Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy (see “Coding Information” below). When billing, providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. This Coverage Policy addresses intensive behavioral interventions (e.g., adaptive behavior treatment, applied behavior analysis). EVERNORTH Coverage Policy: EN0499 1 Coverage Policy Some states mandate coverage of intensive behavioral interventions and/or treatment of autism spectrum disorders (ASD) for benefit plans regulated under state law. For example, New York law requires regulated benefit plans to provide coverage for the screening, diagnosis and treatment of ASD, including applied behavioral analysis. Please refer to the applicable benefit plan document to determine terms, conditions and limitations of coverage. Criteria for Assessment to receive Applied Behavior Analysis (ABA) services An assessment for ABA is considered medically necessary when ALL of the following criteria are met: Diagnosis The individual has a confirmed diagnosis of autism spectrum disorder (ASD); (ICD-10-CM Diagnosis Codes F84.0 – F84.9, with the exception of F84.2, Rett syndrome) based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice and ALL of the following must be provided:  The name, credentials, and type of licensure of the individual who made the diagnosis  The date on which the diagnosis was made Assessment The assessment will be performed by a Board Certified Behavior Analyst (BCBA), Licensed Behavior Analyst (LBA), or a mental health clinician who is licensed to practice independently and who has documented training in ABA. The full and comprehensive ABA assessment will include ALL of the following:  Administration of a reliable, valid, and standardized assessment instrument that measures the individual’s functioning in the domains included in the diagnostic criteria for ASD in the DSM-5-TR as applicable to the individual and their individualized treatment plan/plan of care: social communication and social interaction; and restricted, repetitive patterns of behavior, interests, or activities.  ALL the following must apply in relation to the assessment instrument: o must be completed in its entirety and as designed o the reliability and validity have been established for use with members of the population tested (e.g., age, language preference, etc.) o completed by an individual who has been trained to administer the assessment tool and interpret the results the instrument used represents the most current version, and does not represent obsolete editions of the assessment (e.g., must be the Vineland-3 vs. Vineland-II) the instrument used assesses the individual’s specific and current abilities and skills o o Criteria for Initiation of Treatment with Applied Behavior Analysis (ABA) ABA is considered medically necessary when ALL the following criteria are met: Diagnosis The individual has a confirmed diagnosis of autism spectrum disorder (ASD); (ICD-10-CM Diagnosis Codes F84.0 – F84.9, with the exception of F84.2, Rett syndrome) based on the criteria in the Diagnostic EVERNORTH Coverage Policy: EN0499 2 and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice and ALL of the following must be provided:  The name, credentials, and type of licensure of the person who made the diagnosis  The date on which the diagnosis was made Assessment A full and comprehensive ABA assessment must have been completed that includes all of the criteria from the Assessment for ABA section above regarding the specifications of the assessment tool, as well as ALL of the following criteria:  Standardized scores and score tables and/or scoring grids/figures must be provided, when applicable.  Administration of the assessment instrument must have been completed within 60 days prior to the start of treatment.  The results of the reliable and valid, standardized assessment instrument utilized indicates deficits in areas measuring the domains included in the diagnostic criteria for ASD as defined by the DSM-5- TR: social communication and social interaction; and restricted, repetitive patterns of behavior, interests, or activities.  Results identified through the use of the assessment tool correspond with the content of the skill development and behavior reduction goal(s)/objective(s) included within the submitted treatment plan/plan of care. The assessment must have been performed by a BCBA, LBA, or a mental health clinician who is licensed to practice independently and who has documented training in ABA. In the event the reliable and valid, standardized assessment was completed by a professional other than the requesting provider BOTH of the following criteria are met:  There is clear and documented evidence of collaboration and coordination with the administering professional by the requesting provider.  There is documentation that the assessment results accurately reflect the individual’s current functioning and correspond with the requesting provider's direct observation of the individual. A complete biopsychosocial history has been obtained including:  Relevant co-morbid conditions  Vision and hearing evaluations  Current medications Consideration of family/caregivers, including language or cultural factors that may impact treatment has been documented. Treatment Plan/Plan of Care An individualized treatment plan/plan of care has been developed and provided that includes ALL of the following:  Clearly defined and measurable goals designed to target specific behaviors and skills across all settings and environments where treatment will occur (e.g., home, clinic, school, community setting, etc.) as identified by ALL of the following: o specifically indicates the target behaviors and expectations included for measurement within the treatment goal. identifies the method in which progress will be measured. o EVERNORTH Coverage Policy: EN0499 3 o operationally defines the behavioral expectation of the individual and degree of independence necessary for mastery of the goal/objective.  Treatment goals have been identified and individualized for intervention based on the details and results gathered through the full and comprehensive ABA Assessment (as noted in the sections above) and the individual’s current level of functioning.  Treatment goals are directly related to the symptoms of ASD and their effects as defined by the DSM-5-TR.  Quantitative baseline data have been obtained and provided, with dates recorded, for all behaviors and skills identified for intervention across all settings and environments in which treatment will occur.  When service initiation has occurred greater than 60 days prior to the date of the submission of the authorization request, quantitative baseline, interim and current data have been obtained and provided, with dates on which data were collected, for all of the behaviors and skills identified for intervention across all settings and environments in which treatment will occur/has occurred.  When treatment is delivered, and/or is planned to be delivered, across multiple settings and environments (e.g., home, clinic, school, community setting, etc.), quantitative data have been obtained and provided for all behaviors and skills corresponding within each location of service and in accordance with the reporting specifications noted throughout this section.  Each goal includes clearly defined mastery criteria indicating the standards for determining whether a goal/objective has been/will be met that are consistent with the quantitative units of measurement identified within the goal as well as the quantitative data collection method utilized to report baseline, interim and current data. If group treatment is planned, the treatment plan/plan of care must include clearly defined, measurable goals (see above for specifications) that include ALL of the following:  o are specifically notated to be addressed within the group therapy format o are specific to the individual and their targeted behaviors and skills o include quantitative data (baseline, interim, and current as relevant and applicable) specific to the group therapy format o have been identified for intervention based on the details and results gathered through the full and comprehensive ABA Assessment (as noted in the sections above).  There is a clear plan to ensure maintenance of acquired skills across all settings and environments where treatment will occur.  There is a clear plan to ensure generalization of acquired skills across all settings and environments where treatment will occur.  There is a clearly defined, measurable, individualized, and realistic titration plan that includes a plan for fading services across all settings and environments in which treatment is being or will be provided.  There are individualized discharge criteria that are clearly defined, measurable, realistic, and are directly related to the symptoms of ASD and their effects as defined by the DSM-5-TR indicating the point at which services are appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.  The planned intensity of treatment reflects the severity of the impairments, goals of treatment, and response to treatment across all settings and environments where treatment will occur.  There is a clear and documented plan to coordinate care with all other medical and mental health providers, and with government mandated/school services.  Case supervision will be performed by a BCBA, LBA or a mental health professional who is licensed to practice independently and who has documented training in ABA and includes ALL of the following: o Direct case supervision (occurs concurrently with the delivery of direct treatment to the client and consists of BCBA face-to-face with the individual and either the Registered Behavior Technician [RBT] or the Board Certified Assistant Behavior Analyst [BCaBA]) and indirect case supervision is consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment. EVERNORTH Coverage Policy: EN0499 4 o Direct case supervision time accounts for 50% or more of case supervision. When direct treatment is 10 hours per week or less, a minimum of two hours per week of case supervision is provided. o Supervisory services requested/provided coincide with Current Procedural Terminology (CPT®) code descriptions as identified by the American Medical Association (AMA). o The name and credentials of the individual who will provide supervision must be documented. Stakeholder (e.g., parent/caregiver, relative, teacher, and/or other impacted/invested party) training will be conducted by a BCBA, LBA, or a mental health professional who is licensed to practice independently and who has documented training in ABA and includes ALL of the following:  There are clearly defined, measurable stakeholder goals that are individualized to the stakeholder(s) and the individual individual’s needs designed to teach all relevant stakeholder(s) the basic behavioral principles of ABA and how to continue behavioral interventions in the home and community, as well as across all relevant settings and environments. If group stakeholder training is planned, there are clearly defined, measurable stakeholder training goals for the group training that are individualized to the stakeholder(s) and the individual’s needs.  Quantitative baseline data have been obtained and provided, with dates recorded, for all stakeholder  behaviors and skills identified for intervention across all settings and environments in which treatment will occur.  There is a clear plan to collect data to demonstrate the stakeholder(s) are making progress toward meeting identified stakeholder training goals.  The name and credentials of the individual who will provide stakeholder training must be documented. Services must meet the definition of active treatment / active engagement regardless of location and includes ALL of the following:  Direct service provision consists entirely of active ABA treatment aimed at ameliorating the symptoms of ASD and their effects as defined by diagnostic criteria in DSM-5-TR across all settings and environments where treatment will occur.  The ABA provider must remain in line of sight, direct engagement, and within close enough proximity to the individual to allow for consistent presentation of learning opportunities that relate to the goals and objectives identified within the treatment plan / plan of care (this does not apply to telehealth services, when applicable).  For services that are focused primarily on addressing, preventing or responding to behaviors targeted for reduction (i.e., maladaptive behavior, challenging behavior, behavioral excesses, etc.) the identified behavior(s) must be occurring at a frequency and/or severity (as documented through data collection methods noted above) that requires active intervention throughout the time the ABA provider is with the individual.  ABA services are not utilized to replace or replicate activities that are the responsibility of the setting and environment where services occur (e.g., classroom aide, 1:1 teacher, tutor, vocational assistant/coach, respite services, etc.). Other Factors ABA services delivered by multiple ABA provider organizations/agencies/companies during the same authorization period are not considered medically necessary unless ALL of the following are present and documented:  ABA providers are addressing substantially different skills.  There is a clear plan to coordinate care across providers, to ensure the services are not duplicative, and are consistent with clinical needs of the individual based on documentation and data collection.  Behavioral intervention strategies used across providers are consistent and not contradictory. EVERNORTH Coverage Policy: EN0499 5  The planned intensity of treatment in combination of all ABA providers collectively reflects the severity of the impairments, goals of treatment, and response to treatment across all settings and environments where treatment will occur. When the goals of treatment include feeding conditions and toileting concerns, BOTH of the following must be met:  The treatment plan/plan of care includes specific safety measures and protocols.  Consultation with medical and/or dietary/nutritional professionals has occurred prior to the initiation of the intervention, will be continued on an ongoing basis, and is specifically documented. When the goals of treatment are implemented as part of Severe Behavior Programs and/or include severe behavior, ALL of the criteria from initiation of treatment section (and continued treatment section as applicable) are currently met, as well as ALL of the following must be met:  A complete treatment history is obtained and documented including relevant co-morbid conditions, current medications, previous treatment/intervention (including participation in higher levels of care as applicable), and any currently implemented treatment/intervention.  A complete history of the targeted severe behavior(s) is obtained and documented (e.g., involvement of emergency services, bodily injury, collateral damage, property destruction, distance/duration of elopement, etc.).  Response to previous and/or current treatment is documented indicating necessity of participation in Severe Behavior Program.  Administration of the assessment instrument must have been completed by the requesting provider or by a professional other than the requesting provider (see above Assessment sections for criteria) within 60 days prior to the start of treatment.  Quantitative baseline (interim and current as applicable) data (e.g., rate, duration, intensity, and/or episodic severity) of targeted behavior have been obtained, and provided, with dates on which data were collected, for all behaviors and skills identified for intervention as obtained through consultation/coordination with current ABA provider (as applicable) and/or direct observation by the requesting Severe Behavior Program provider.  Data presented in relation to target behavior meet the definition of Severe Behavior.  The treatment plan/plan of care includes specific safety measures and protocols.  Consultation with medical and/or mental health professionals has occurred prior to the initiation of the intervention, will be continued on an ongoing basis, and is specifically documented. When authorization requests involve coverage of services conducted retrospectively, ALL of the criteria from initiation of treatment section (and continued treatment section as applicable) are met, coinciding with the dates of service identified within the request. Criteria for Continued Treatment with ABA Continued treatment with ABA is considered medically necessary when: (1) the first bullet in the above section for initiation of treatment section was met at the time treatment was initiated; (2) ALL of criteria from initiation of treatment section above are currently met and (3) ALL of the following criteria are met: The treatment plan/plan of care has been updated to address the current identified skill deficits and behaviors, as well as progress made across all targeted areas. Quantitative baseline, interim and current data have been obtained, and provided, with dates on which data were collected, for all behaviors and skills previously identified and/or proposed for intervention (as applicable) across all settings and environments where treatment has been provided or will occur. The data indicate that there has been ongoing and sustained progress toward mastering the treatment goals. EVERNORTH Coverage Policy: EN0499 6 There is evidence of measurable and ongoing improvement in targeted behaviors and skills as demonstrated with the use of a reliable and valid, standardized assessment instrument completed no more than one year from the start date of the continued treatment request. When progress toward mastering treatment and/or stakeholder goals, or evidence of measurable and ongoing improvement is not demonstrated, barriers toward progress have been identified, and there is a specific and documented plan to address barriers and evidence of interventions being adjusted through protocol modification, with continued data monitoring and assessment for effectiveness by the provider. When behaviors and skills have been identified for new and/or proposed intervention (e.g, goals and objectives), baseline data have been obtained and provided, with dates recorded across all settings and environments in which treatment will occur, or are planned to occur, and are updated as necessary to have been collected within no more than 30 days prior to the implementation of the intervention associated with the identified behavior and skill. Administration of a reliable and valid, standardized assessment instrument is completed following any break in treatment greater than 60 calendar days. Updated/current data have been collected with dates on which data was collected, for all behaviors and skills identified for intervention across all setting and environments in which treatment will occur following any break in treatment greater than 60 calendar days. Quantitative baseline, interim and current data related to stakeholder training goals have been obtained and provided, with dates on which data were collected, indicating all relevant stakeholders continue to actively participate in the treatment and that they are making sustained and ongoing progress toward mastering the stakeholder goals. When an increase in treatment intensity is requested either within a currently authorized period, or at the start of a subsequent authorization period, the request should include ALL of the following (in additional to the details of the relevant sections noted throughout this document):  Description and clinical rationale related to the increase in treatment intensity  Evidence and quantitative data demonstrating how the increase in intensity would improve outcome.  Description and quantitative data related to how the increase in intensity would be utilized, as well as its clinical basis. Documentation Expectations A separate written record is expected for each individual receiving ABA intervention corresponding with each service noted through identified CPT® Code that includes at least ALL of the following: Start date and time for each service • End date and time for each service • Location of service delivery • The focus of service • A detailed description of intervention conducted by the ABA provider during the time of service • • The specific service delivered (e.g., direct service, supervision, stakeholder training, etc.) • Name, credential (if applicable), and signature of ABA provider who rendered the service Individuals present during the time of service Not Covered or Reimbursable Applied Behavior Analysis (ABA) is not covered or reimbursable for all non- autism spectrum disorders (ASD) indications including Rett syndrome. Intensive behavioral interventions other than ABA are not covered or reimbursable. EVERNORTH Coverage Policy: EN0499 7 Services that are considered primarily educational or vocational in nature, or related to academic or work performance are not covered or reimbursable. Provision of ABA treatment is not covered or reimbursable when delivered to the same individual, at the same time as any other treatment modality (e.g., ABA and speech therapy, or ABA and occupational therapy). General Background Glossary of Terms TERM Active Treatment / Active Engagement Applied Behavior Analysis Assessment Baseline Data Clearly Defined Goals Clinical Note Comprehensive ABA Continued Treatment with ABA Authorization Request Criterion Referenced DEFINITION Treatment is performed in a manner in which the interventionist is within close enough proximity to the individual to allow for direct engagement in presenting, creating and/or contriving consistent learning opportunities based on structured, planned and intentional intervention strategies or naturally occurring environmental stimuli. Active treatment involves regular engagement of an individual and their significant others and may include both systematic and naturalistic techniques across both individual and group settings (Association of Professional Behavior Analysts [APBA], 2017; Pellecchia, et al., 2015). The science in which tactics derived from the principles of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change (Cooper, et al., 2020). A developmentally appropriate evaluation tool to ascertain areas of relative strength and deficit across relevant domains and informs the development of an individualized treatment plan/plan of care, including recommendations for areas of focus, goals of treatment, intensity of service, and mode of service delivery (Council of Autism Service Providers [CASP], 2020). Quantifiable information regarding performance of skill development and behavior reductive targets (as applicable) collected prior to implementation of the independent variable identified as intervention/treatment from which areas of treatment focus and intervention can be identified, the effects of the independent variable can be recognized, and comparative progress can be determined (see Demonstration of Progress). Reporting of baseline data includes dates on which the information was collected (Cooper, et al., 2020). Specifically indicates the target behaviors and expectations included for measurement within the treatment goal. Identifies the method in which progress will be measured. Operationally defines the behavioral expectation of the individual and degree of independence necessary for mastery of the goal/objective. Requirements for written record of documentation for each CPT® code billed that includes the start date and time for each service, the end date and time for each service, location of service, the focus of service, a detailed description of what was conducted by the provider during the time of service demonstrating ABA treatment was performed, who was present/who participated in the service, and who rendered the service. Signatures and time stamps of when the note was completed are included. May also be referred to as “Progress Note,” "Psychotherapy Note," or “Session Note” (United States, The Health Insurance Portability and Accountability Act, 2004). ABA treatment of multiple affected developmental domains, which may also include reduction of maladaptive behaviors (CASP, 2020). An ABA treatment authorization request when, regardless of funding source, the individual has participated in ABA services with the requesting provider within 90 days from the date the authorization request was made. A psychometric property of a standardized assessment that relates to some unit of measure based on the test taker's performance on a set of standard criteria. Scores on EVERNORTH Coverage Policy: EN0499 8 TERM DEFINITION Assessments Current Data Data Demonstration of Progress criterion referenced assessments are developed by demonstration of a particular skill, milestone or measurable outcome, and are not impacted by other test takers' performances (Patten & Newhart, 2018). Quantitative information regarding performance generally collected within 30 days prior to when the treatment plan/plan of care is submitted, which includes dates on which the information was collected. The identification of some dimension of behavior, as collected through measurement procedures and presented in a quantifiable format (Cooper et al., 2020). Quantitative information regarding performance as demonstrated through current data in relation to treatment goals/objectives and/or formally administered assessment results, indicating comparable, measurable and meaningful behavior change in relation to quantifiable baseline and/or interim data. Demonstration of progress indicates practical importance when altering of the behavior produces socially significant and socially important change (Baer et al., 1968). Diagnosis Tracking of progress of goals and within delivered treatment services should be demonstrated through measurement systems that are individualized, the treatment environment, and the context within which services are conducted (CASP, 2020). A diagnosis of autism spectrum disorder (ASD) is confirmed when the diagnosis has been made based on the criteria in the DSM-5-TR. A confirmed diagnosis of ASD may also be termed a “medical diagnosis” of ASD when the diagnosis is made by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice. Direct Case Supervision Discharge Criteria Focused ABA Generalization By contrast, educational identification or meeting educational eligibility for services related to autism through the Individuals with Disabilities Education Act (IDEA) may not meet criteria as a formal diagnosis of ASD, unless the above mentioned specifications have also been met. Similarly, a diagnosis is not considered confirmed when it has been termed “provisional,” “proposed,” “potential,” “at risk of,” “rule out” or any other term used by the diagnosing clinician to indicate that more information may be necessary prior to confirming the diagnosis. Occurring concurrently with direct treatment, the BCBA is face-to-face with the individual and the technician (e.g., RBT or the BCaBA) delivering the direct treatment. This can include direct observation of treatment by technician, clinical direction on new and revised treatment protocols, and/or monitoring integrity (CASP, 2020). Clearly defined, measurable, realistic, and individualized criteria indicating the point at which services are appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care. Criteria should identify quantifiable skill development and behavior reductive targets considered necessary and socially significant, specific to the individual, and be related to the current course of treatment identified through the individual’s treatment plan/plan of care. Discharge criteria should be identified at initiation of treatment and reviewed and adjusted as appropriate throughout the course of services (ABA Coding Coalition, 2022; CASP, 2020). ABA treatment provided directly to the individual for a limited number of behavior targets (CASP, 2020). Behavior change that is durable over time, appears in a wide variety of possible environments, can be demonstrated across individuals, or spreads to a wide variety of related behaviors (Baer, et al., 1968). Goals/Objectives Specific, clearly and operationally defined, measurable, realistic and individualized description of the precise skill development and behavior reductive targets that represent the focus of intervention within the treatment plan/plan of care. Treatment goals/objectives are based on the areas of deficit identified through the assessments/evaluations administered and include data collection procedures that are consistent with mastery criteria and allow for frequent evaluation. Treatment EVERNORTH Coverage Policy: EN0499 9 TERM Indirect Case Supervision Initiation of Treatment with ABA Authorization Request Interim Data Maintenance Mastery Criteria Measurable Goals Multiple Procedures Norm Referenced Assessments Observational Treatment Operational Definition Qualitative Data DEFINITION goals/objectives indicate the number of targets required toward meeting mastery criteria (when applicable) and are consistent with the intensity and setting of service provision. New treatment goals/objectives are considered on a consistent basis (CASP, 2020). Case supervisory activities occurring outside of the treatment setting and/or without contact with the client or relevant stakeholders. This can include development of treatment goals, protocols, and data collection systems, analysis of data, evaluation of progress, coordination of care activities with other professionals, meetings with direct staff outside of the treatment setting or without the client present (CASP, 2020). An ABA treatment authorization request when the individual has not participated in ABA services with the requesting provider within 90 days from the date the authorization request was made. Quantitative information regarding performance from the period of time between when the goal was introduced into treatment and one month prior to the time the treatment plan/plan of care was submitted for review. Reporting of interim data includes dates on which information was obtained. At a minimum, interim data should include the data point as collected for the previous review period. The extent to which the individual continues to perform the target behavior after a portion or all of the intervention has been terminated (Cooper, et al., 2020). Socially validated performance criteria (Cooper, et al., 2020) that includes quantitative and measurable conditions and standards that are clearly defined, based on collected data that identifies when a particular target, goal, objective, skill set or behavior has been achieved/accomplished and no longer requires focused and targeted treatment/intervention. Mastery criteria should be consistent with the units of measurement identified within the goal indicating the standards for determining when a goal/objective has been/will be met and specifies the number of targets required to meet the goal/objective (when applicable). Indicates the method in which data will be collected as a means of demonstrating progress toward mastery of the treatment goal. Includes an operational description of the target behavior using quantifiable terms. Measurable goals incorporate quantitative data collection that coincides with data collection methods used for identifying baseline data, interim data and description of progress through current data. Regardless of the funding source, multiple providers bill for services rendered to the same individual when those services occur at the same time. Also referred to as concurrent billing (American Medical Association [AMA], 2022). A psychometric property of a standardized assessment that is designed to compare and rank test takers in relation to the general population. Norm referenced assessments allow for appraisal of the test taker to a hypothetical average test taker, which is determined by comparing scores against the performance results of a statistically selected group of test takers, typically of the same age or grade level (Patten & Newhart, 2018). Treatment is performed in a manner in which the interventionist does not present consistent learning opportunities (related to reduced proximity and/or limited occasion), and engagement with the individual and their significant others is inconsistent, infrequent, irregular and unreliable. Clearly stated description of the behavior characteristics that is observable, measurable, repeatable and agreeable (Alberto & Troutman, 2013). Categorized based on traits and characteristics (e.g., anecdotal accounts, descriptive reports, etc.) (Kazdin, 2011). Counted or measured and reported using numbers (e.g., rate, frequency, percent of opportunities, cumulative mastered targets, percent of momentary time sampling, etc.) (Kazdin, 2011). Quantitative Data EVERNORTH Coverage Policy: EN0499 10 TERM Reliable Assessments Retrospective Treatment with ABA Authorization Request Severe Behavior Severe Behavior Program DEFINITION An assessment instrument that produces consistent results across administrations, and when implemented by different people (Patten & Newhart, 2018). A retrospective authorization request is any request made after a specific amount of time for both initial and continued stay requests. A retrospective authorization request for ABA is any request made when more than 90 days have passed since the start date of the requested authorization, or any time after the individual has discharged. Behaviors occur at a rate, duration, intensity and/or episodic severity that directly interferes with autonomy and independence, as well as participation in available learning opportunities presented both through the natural environment and applied treatment programs (as applicable). Behaviors are destructive and disruptive to daily life, may result in a risk of harm, and are considered dangerous to the individual, those in direct vicinity of the individual, and/or property (Salvatore, et al., 2022). Destructive behaviors may include but are not limited to “… self-injurious behavior, aggression, property destruction, pica, elopement, and other behaviors associated with high-risk medical consequences or property damage.” (CPT® Assistant November 2018 / Volume 28 Issue 11) Provide treatment focused with individuals who engage in Severe Behavior. Participation in treatment is often short-term and directed specifically toward analysis, evaluation, remediation, replacement and/or reduction of severe behavior (Fisher, et al., 2021). Behaviors that have immediate and long-lasting effects for the person and for those who interact with that person (Cooper, et al., 2020). Socially Significant Behaviors Stakeholder(s) Standardized Assessments Titration Plan Treatment Plan / Plan of Care Valid Assessments An individual, other than the person directly receiving services, who is impacted and invested in the intervention provided (e.g., parent/caregiver, relative, teacher, etc) (BACB, 2021). Requires all test takers to answer the same questions or meet the same criteria. Tests are administered and scored in a similar manner across participants to allow for comparison of performance across administrations and with other test takers (Patten & Newhart, 2018). Written plan with treatment targets that must be achieved for each step of a gradual step down in services (CASP, 2020). Submitted documentation outlining the course and direction of intervention that guides procedures, and determines recommendations for areas of focus, goals of treatment, intensity of service, and mode of service delivery (Luiselli, 2006). Treatment plans / plans of care include information to substantiate that the medical necessity criteria for Applied Behavior Analysis as outlined in Evernorth Behavioral Health Coverage Policy EN0499 Intensive Behavioral Interventions are met. An assessment instrument that has been psychometrically tested for reliability (see Reliable Assessments), validity (refers to the test's ability to measure what it is intended to measure), and sensitivity (the probability that the assessment will accurately identify and distinguish test taker's performance in meeting set criteria) (Patten & Newhart, 2018). Autism Spectrum Disorder (ASD) is a developmental disability characterized impairments in reciprocal social communication and social interaction, and restricted, repetitive patterns of behavior, interests, or activities. Deficits often occur across multiple contexts and may result in challenges across multiple areas of functioning. Symptoms associated with ASD must be present in the early developmental period but may not be identified until later. The presentation, impact, and severity of characteristics associated with ASD may vary greatly amongst individuals who meet criteria for the diagnosis. EVERNORTH Coverage Policy: EN0499 11 Etiology The precise etiology of ASD is unknown, although there appears to be a high heritability associated with it. The etiology can be identified for between 15% and 20% of individuals with autism; in the others the cause remains unknown. This is a field of active research. Associations between ASD and a number of other medical conditions have been proposed. Other medical conditions include but are not limited to: Epilepsy or seizure disorder • Tuberous sclerosis • Fragile X syndrome • Intellectual disability American Academy of Child & Adolescent Psychiatry (AACAP): The American Academy of Child & Adolescent Psychiatry (AACAP) 2022 Policy Statement on Autism and Vaccines states “Multiple studies conducted in several different countries have demonstrated that there is no causal association between vaccines or their preservatives and ASD. Further, vaccines do not change the timing of the onset of ASD symptoms, nor do they affect the severity of ASD symptoms. Even in families who have a greater risk for ASD, such as those who already have a child with ASD, there is no increased likelihood that the second child will have ASD if vaccinated” (AACAP, 2022). American Academy of Pediatrics (AAP): The AAP 2020 Clinical Report on Identification, Evaluation, and Management of Children With Autism Spectrum Disorder states that “The scientific literature does not support an association of vaccination as an environmental factor that increases the risk for ASD. Children with ASD should be vaccinated according to the recommended schedule” (AAP/Hyman, et al., 2020) Diagnostic criteria for Autism Spectrum Disorder from: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) A. 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, no exhaustive; see text of DSM-5-TR) 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 lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior. B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, no exhaustive; see text of DSM-5): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor 2. stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). 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). EVERNORTH Coverage Policy: EN0499 12 Diagnostic criteria for Autism Spectrum Disorder from: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) 4. Hyper- or hyporeactivity to sensory input 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 of objects, visual fascination with lights or movement). Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior. C. Symptoms must be present in the early developmental period (but may not be fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life. D. Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning. E. These disorders 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 diagnosis of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. The DSM-5-TR notes that individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specific 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. Health Disparity The Autism and Developmental Disabilities Monitoring (ADDM) Network is a program funded by Centers for Disease Control and Prevention (CDC) to collect data to better understand the number and characteristics of children with autism spectrum disorder (ASD) and other developmental disabilities living in different areas of the United States. In 2020, there were 11 ADDM Network sites across the United States. Key Findings from the ADDM Network (A Snapshot of Autism Spectrum Disorder in 2020) included: More children who were born in 2016 (1.8%) received an ASD diagnosis or special education classification by 4 years of age compared with children born in 2012 (1.1%), suggesting progress in early ASD identification over time. Prior to the start of the COVID-19 pandemic, 4-year-old children were receiving more evaluations and identifications than 8-year-old children did when they were 4 years of age. However, around the start of the COVID-19 pandemic in March 2020, the rate of evaluation and ASD identification decreased dramatically among 4-year-old children compared with 8-year-old children when they were 4 years of age. Evaluations and ASD identification did not return to pre-pandemic levels through the end of 2020. About 1 in 36 (2.8%) 8-year-old children were identified with ASD by the ADDM Network. • Also in 2020, Black, Hispanic, and Asian or Pacific Islander children had a higher percentage of ASD than White children for the first time among 8-year-olds. Specifically, ASD prevalence was lower among non-Hispanic White children (24.3) and children of two or more races (22.9) than among non-Hispanic Black or African American (Black), Hispanic, and non-Hispanic Asian or Pacific Islander (A/PI) children (29.3, 31.6, and 33.4 respectively). Among 8-year-old children, boys were nearly 4 times as likely as girls to be identified with ASD. However, 2020 marked the first time the ADDM Network found the percentage of girls identified with ASD to be over 1%. Among 8-year-old children identified with ASD who had intelligence quotient (IQ) scores available, more than one-third (37.9%) also had intellectual disability (CDC, 2023; Maenner, et al., 2023; Shaw, et al., 2023). Intensive Behavioral Interventions Intensive behavioral interventions are comprehensive treatment programs that utilize a combination of interventions with the aim of improving cognitive and intellectual function, social and adaptive skill development and behavior problems. They have been proposed to treat autism spectrum disorders as well as other conditions EVERNORTH Coverage Policy: EN0499 13 that involve behavioral difficulties. The programs emphasize early intervention, individualization of treatment and an intensive approach. The programs may also be referred to as early intensive behavior intervention (EIBI), intensive behavior intervention (IBI) or early intensive behavioral treatment (EIBT). At times, the terms EIBI, IBI, EIBT are used interchangeably with applied behavior analysis (ABA), Lovaas therapy or Lovaas University of California Los Angeles (UCLA) Program. The term intensive behavioral interventions is used in this coverage policy, but this aligns with Adaptive Behavior Treatment that is referenced in Current Procedural Terminology (CPT®) codes section. Behavior Analyst Certification Board, Inc.® (BACB®) There is a formal credentialing process of professional behavior analysts through the Behavior Analyst Certification Board® (BACB). The BACB offers 3 certifications at different experience levels: Board Certified Behavior Analyst® (BCBA®): A graduate-level professional in behavior analysis who is able to practice independently and provide supervision for BCaBAs and RBTs. Board Certified Assistant Behavior Analyst® (BCaBA®) - An undergraduate-level professional in behavior analysis who practices under the supervision of a BCBA or FL-CBA. Registered Behavior Technician® (RBT®) - A paraprofessional in behavior analysis who practices under the close, ongoing supervision of a BCBA, BCaBA, or FL-CBA. (Source: https://www.bacb.com/) Council of Autism Service Providers (CASP) The Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (CASP, 2020) provides clinical guidelines and other information about ABA as a treatment for ASD. As a behavioral health treatment, ABA includes a number of unique clinical and delivery components. Thus, it is important that those charged with building a provider network understand these unique features of ABA. (The ASD Practice Guidelines were originally published by the Behavior Analyst Certification Board. In March 2020, the Guidelines were transferred to CASP. The CASP Practice Guideline notes that the BACB® credentials and recognizes practitioners at four levels, including those mentioned above as well as a Board Certified Behavior Analyst – Doctoral™ (BCBA-D®). (Source: https://www.casproviders.org/asd-guidelines) The main characteristics of ABA should be apparent throughout all phases of assessment and treatment and include the following (CASP, 2020): An objective assessment and analysis of the individual’s condition by observing how the environment affects the client’s behavior, as evidenced through appropriate data collection. Importance given to understanding the context of the behavior and the behavior’s value to the individual, the family, and the community. Utilization of the principles and procedures of behavior analysis such that the individual’s health, independence, and quality of life are improved. Consistent, ongoing, objective assessment and data analysis to inform clinical decision-making. There are two treatment models that exist on a continuum, Focused or Comprehensive ABA treatment. Focused ABA treatment may involve increasing socially appropriate behavior or reducing problem behavior. Individuals who need to acquire skills (e.g., communication, tolerating change in environments and activities, self-help, social skills) are appropriate for Focused ABA. Focused ABA may be delivered individually or as part of a small- group format. Key functional skills can include, establishing instruction-following, social communication skills, compliance with medical and dental procedures, sleep hygiene, self-care skills, safety skills, and independent leisure skills (e.g., appropriate participation in family and community activities). Severe problem behaviors that may require focused intervention can include, but are not limited to, self-injury, aggression, threats, pica, elopement, feeding disorders, stereotypic motor or vocal behavior, property destruction, noncompliance and disruptive behavior, or dysfunctional social behavior (CASP, 2020). There are times when an individual with ASD has co-occurring severe destructive behavior disorders that require focused treatment in more intensive settings, such as Severe Behavior Programs that have specialized intensive-outpatient, day-treatment, residential, or inpatient programs. The ABA services delivered in Severe Behavior Programs often require higher staff-to-client ratios with close on-site direction from the Behavior Analyst. Additionally, such treatment programs often have specialized treatment environments (for example, EVERNORTH Coverage Policy: EN0499 14 treatment rooms designed for observation and to keep the individual and the staff as safe as possible). Participation in severe behavior treatment is often short-term and directed specifically toward analysis, evaluation, remediation, replacement and/or reduction of severe behavior. An assessment should include the following: complete treatment history, which includes previous evaluations, diagnoses, and interventions, as well as a complete history of the targeted severe behavior(s) with response to current and/or previous treatment. Goals should be outcome oriented with clearly defined goals for each patient. Treatment decisions should be based on objective and ongoing measures of the individual’s destructive behavior (Fisher, et al., 2021; CASP, 2020). Comprehensive ABA is treatment of the affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypy are the focus of treatment. These programs tend to range from 30–40 hours of treatment per week (plus direct and indirect supervision and caregiver [stakeholder] training). Initially, this treatment normally involves 1:1 staffing and gradually includes small-group formats. Comprehensive treatment can be appropriate for older individuals diagnosed with ASD, particularly if they engage in severe or dangerous behaviors across environments (CASP, 2020). The assessment process for developing an individualized ABA treatment plan includes medical record review for the individuals’ medical status, prior assessment results, response to prior treatment and other relevant information may be obtained via file review and incorporated into the development of treatment goals and intervention. Individuals, caregivers, and other stakeholders are included when setting treatment goals, developing protocols, and evaluating progress. Additionally, direct assessment and data collection are needed to identify pretreatment levels of functioning, developing and adapting treatment protocols on an ongoing basis, and evaluating response to treatment and progress toward goals. Behavior should be directly observed in a variety of relevant naturally occurring settings and structured interactions (CASP, 2020). ABA treatment goals are identified based on the assessment process. Each goal should be defined in a specific, measurable way to allow frequent evaluation of progress toward a specific mastery criterion. Each goal and objective must be individualized and include (CASP, 2020): Current level (baseline) • Behavior parent/caregiver is expected to demonstrate, including condition under which it must be demonstrated and mastery criteria (the objective or goal) Date of introduction • Estimated date of mastery • Specify plan for generalization • Report goal as met, not met, modified and include explanation Case supervision activities can be described as those that involve contact with the client or caregivers (direct supervision) and those that do not (indirect supervision). Direct case supervision occurs at the same time as the delivery of direct treatment to the individual. Direct supervision typically accounts for 50% or more of case supervision and be responsive to individual client needs. The general standard is two hours for every 10 hours of direct treatment. When treatment is less than 10 hours per week a minimum of two hours per week of case supervision is required (CASP, 2020). Stakeholder (e.g., parent/caregiver, relative, teacher, and/or other impacted/invested party) training is a part of both Focused and Comprehensive ABA treatment models. Training involves a systematic, individualized curriculum on the basics of ABA. Treatment plans include multiple objectives and measurable goals for parents and the stakeholder. Training involves an individualized behavioral assessment, a case formulation, and then customized educational presentations, modeling and demonstrations of the skill, and practice for each specific skill (CASP, 2020). Transition and discharge planning should be individualized and include a written plan with specific details of monitoring and follow-up. Parents, community caregivers, and other involved professionals should be consulted as the planning process accelerates with three to six months prior to the first change in service. Discharge and transition planning involve a gradual step down in services and can require six months or longer (CASP, 2020). American Academy of Pediatrics (AAP) EVERNORTH Coverage Policy: EN0499 15 The AAP 2020 Clinical Report on Identification, Evaluation, and Management of Children With Autism Spectrum Disorder notes the following: Most evidence-based treatment models are based on principles of applied behavior analysis (ABA). ABA has been defined as “the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior.” The use of ABA methods to treat symptoms of ASD suggests that behaviors exhibited can be altered by programmatically reinforcing skills related to communication and other skill acquisition. Thus, ABA treatments may target development of new skills (eg, social engagement) and/or minimize behaviors (eg, aggression) that may interfere with a child’s progress ABA interventions vary from highly structured adult-directed approaches (eg, discrete trial training or instruction, verbal behavior applications, and others) to interventions in natural environments that may be child led and implemented in the context of play activities or daily routines and activities and are altered on the basis of the child’s skill development (eg, pivotal response training, reciprocal imitation training, and others). A comprehensive ABA approach for younger children, also known as early intensive behavioral intervention, is supported by a few randomized controlled trials (RCTs) and a substantial single-subject literature (AAP/Hyman, et al., 2020). Agency for Healthcare Research and Quality (AHRQ) In 2014, the AHRQ published a systematic review that updated the behavioral intervention portion of the comprehensive review of therapies for children with ASD that was published in 2011 (Weitlauf, et al., 2014). The review included 65 studies comprising 48 randomized trials and 17 nonrandomized comparative studies (19 good, 39 fair, and 7 poor quality) published since the prior review. The quality of studies improved compared with the earlier review; however, the assessment of the strength of evidence (SOE), confidence in the stability of effects of interventions in the face of future research, remains low for many intervention/outcome pairs. The authors concluded that a growing evidence base suggests that behavioral interventions can be associated with positive outcomes for children with ASD; however, despite improvements in the quality of the included literature, a need remains for studies of interventions across settings and continued improvements in methodologic rigor. Substantial scientific advances are needed to enhance understanding of which interventions are most effective for specific children with ASD and to isolate elements or components of interventions most associated with effects. Cochrane Review In a 2018 Cochrane Review, Reichow et al. reviewed the evidence for the effectiveness of Early intensive behavioral intervention (EIBI) in increasing functional behaviors and skills, decreasing autism severity, and improving intelligence and communication skills for young children with ASD. The review included five studies (one RCT and four controlled clinical trials [CCTs]) with a total of 219 children: 116 children in the EIBI groups and 103 children in the generic, special education services groups. The age of the children ranged between 30.2 months and 42.5 months. Three of the five studies were conducted in the USA and two in the UK, with a treatment duration of 24 months to 36 months. All studies used a treatment-as-usual comparison group. The authors found evidence at post-treatment that EIBI improves adaptive behavior (5 studies, 202 participants; low-quality evidence) and found no evidence at post-treatment that EIBI improves autism symptom severity (2 studies, 81 participants; very low-quality evidence). No adverse effects were reported across studies. • The author found evidence at post-treatment that EIBI improves IQ (5 studies, 202 participants; low- quality evidence) and expressive (4 studies, 165 participants; low-quality evidence) and receptive (4 studies, 164 participants; low-quality evidence) language skills. They found no evidence at post-treatment that EIBI improves problem behavior (2 studies, 67 participants; very low-quality evidence). They noted that additional studies using rigorous research designs are needed to make stronger conclusions about the eHects of EIBI for children with ASD (Cochrane Review / Reichow, et al., 2018). Other Intensive Intervention Programs EVERNORTH Coverage Policy: EN0499 16 Intensive intervention programs other than those that focus on behavior analytic treatment have also been developed. The published evidence is preliminary and does not support the efficacy of these programs. These include, but are not limited to: TEACCH program: The TEACCH program (Treatment and Education of Autistic and Related Communication Handicapped Children) is an educational intervention focused on improving motor coordination and cognitive skills and has been implemented in many special education programs for autistic children. It includes behavioral analytic approaches for some skills but uses other interventions as well. Denver Model: The focus of the Colorado Health Sciences program (Denver Model) is learning through play based on Piaget and object relations theories. Behavior analytic techniques are included for behavior management. Rutgers program: The Rutgers program is known as the Douglass Developmental Disabilities Center (based at Rutgers University), has three programs small group segregated preschool, and integrated preschool and intensive home-based intervention, and uses ABA techniques and similarities to the Lovaas program. Families are trained in the program and provide the treatment when they are available and or hire staff trained in the program. Learning Experiences and Alternative Program (LEAP): LEAP program includes both a preschool program and a behavioral skill training program for parents, as well as national outreach activities. The program includes an individualized curriculum that targets goals in social, emotional, language, adaptive behavior, cognitive, and physical developmental areas. Relationship Development Intervention (RDI): RDI is a program designed to empower and guide parents of children, adolescents and young adults with ASD and similar developmental disorders to function as facilitators for their children’s mental development. RDI is based on instructing the parents to have an important role in improving critical emotional, social and meta-cognitive abilities through carefully graduated, guided interaction in daily activities. Floortime: this is also referred to as DIR® (Developmental, Individual Difference, Relationship-based model), DIR® Floortime, or Greenspan Floor-Time Model. This is a developmentally-based, one-on-one treatment program delivered 10 to 25 hours per week. The primary intervention method used in this model is intensive interactive “floor-time” play sessions, in which an adult follows a child’s lead in play and interaction. The program consists of three components: home-based play sessions, individual therapies, and early education programs. Intensive Behavioral Interventions for Other Conditions Although intensive behavioral interventions were developed initially to treat children with autism spectrum disorders (ASD) they have been proposed to treat children with other conditions, including Down syndrome, learning disabilities and Attention-Deficit/Hyperactivity Disorder (ADHD). There is a lack of scientific evidence to support the efficacy of the programs for other conditions. ABA has been proposed to treat individuals with Down syndrome. The behavior and psychiatric problems associated with Down syndrome Assessment should include evaluation of the problem at school and at home, behavior management techniques, and medication as needed (Ostermaier, 2022). The role of ABA in treatment of this condition is unproven (Neil, et al., 2021; Feeley, et al., 2008).