BH Applied Behavioral Analysis for Down Syndrome Form

1

Applied Behavioral Analysis for Down Syndrome-
Behavioral Health Policy Updated Revision Effective: January 1, 2026 Policy Number: UM1062POL

Approval Date: 8/14/2025

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

As stated in the UM Program policies and procedures, prior approval is required for Applied Behavioral Analysis (ABA) for Down Syndrome. The HNE Clinical Reviewer reviews the authorization request as per the Clinical Review Criteria and according to the procedure set forth in the policy titled, Prior Approval by Health Services.

Effective January 1, 2026, HNE will provide coverage for medically necessary ABA Therapy and habilitative services for members with a definitive diagnosis of Down Syndrome for all fully funded plans and for any self-funded plan that elects this coverage.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Medical necessity review is performed by the Massachusetts Behavioral Health Partnership (MBHP).

Medicare:
This policy does not apply

2

Policy

I. Coverage

The ABA coverage for Down Syndrome is provided consistently with the requirements in the state of Massachusetts beginning 1/1/2026, with coverage pursuant to Chapter 388 of the Acts of 2024.

ABA includes the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior. It also includes the use of direct observation, measurement and functional analysis of the relationship between environment and behavior.

A Board-Certified Behavior Analyst (BCBA) professional conducts behavioral assessments, designs and supervises behavior and analytical interventions and also develops and implements assessments and interventions for members with diagnoses of autism spectrum disorders.

A BCBA may supervise the work of other BCBAs and other ABA Paraprofessionals who implement behavioral analytic interventions.

Habilitative care is provided by professionals and is “necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual” diagnosed with Down Syndrome.

A. To bill for ABA services, the Provider must be contracted and credentialed by HNE, be actively certified as a BCBA by the Behavior Analyst Certification Board (BACB), and have an active Behavior Analyst License.

B. To bill for ABA services delivered by a paraprofessional, the Provider must meet all of the criteria to bill for ABA services and perform ALL of the following for each paraprofessional that he or she supervises:

1. Provide clinical oversight to each paraprofessional

2. Assume ultimate responsibility for ABA services delivered by the paraprofessional

3. Agree not to bill for ABA services delivered by a member of the patient’s family

4. Perform a Criminal Offender Record Information (CORI) check on each paraprofessional

5. Verify that each paraprofessional is a credentialed Registered Behavior Technician (RBT)

6. Inform the member who receives services from a paraprofessional and the member’s caregiver of the paraprofessional status

7. Create and maintain a medical record and ensure that each hour of service is appropriately documented.

   II. Prior Approval (PA) Process

   A. Functional Behavioral Assessment (FBA)

   a. The Prior Authorization Request Form (PARF) for ABA Functional Behavioral Assessment (FBA) is fully completed, including identification of the referring provider along with the completed diagnostic evaluation (full document) that determined that the member has a Down Syndrome diagnosis.

3

B. Applied Behavioral Analysis (ABA) service

C. Following completion of the ABA FBA, the ABA for Down Syndrome PARF is submitted including the completed Functional Behavior Assessment.

1. Following completion of the above, the ABA for Down Syndrome PARF is submitted, to which the report of the Functional Behavior Assessment must be attached.

   III. Criteria for approval

   A. HNE may authorize ABA therapy visits and/or habilitative care visits after a comprehensive diagnostic evaluation by a Neurologist, Pediatric Neurologist, Developmental Pediatrician, Member of Certified Early Intervention Team, Psychologist , Psychiatrist or a Pediatrician certified to use an accepted diagnostic tool, experienced in the diagnosis of Down Syndrome and with a referral (as needed) when all of the below are met:

2. The Member has a definitive diagnosis of Down Syndrome from a Neurologist, Pediatric Neurologist, Developmental Pediatrician, Member of Certified Early Intervention Team, Psychologist or Psychiatrist experienced in the diagnosis and treatment of Down Syndrome AND;

3. From the initial request for ABA through the entire course of treatment, all of the following must be met:
   a. Documentation must support the position that therapy will achieve functional gains beyond those expected as a result of growth and maturation and there is clear evidence that the symptoms of the illness are active, resulting in substantial impairment in daily functioning AND.

   b. There is a clear treatment plan, measurable goals and approaches that address the signs and symptoms of the illness. Treatment plans should include: AND;

   c. There is no less intensive or more appropriate level of services which can be safely and effectively provided AND

   d. ABA services including habilitative services must be provided or supervised by a BCBA or by a licensed provider AND;

   e. There are clearly defined, measurable goals for the parent/guardian/caregiver, which are documented in the treatment plan, and tracked in the ongoing clinical progress notes. Parent/guardian/caregiver involvement in treatment is critical to the fidelity of the ABA model, as well as for the generalization of treatment goals across settings, and for eventual completion of treatment AND.

   f. The Member’s condition can be classified and billed with the codes listed below.

4. For ongoing services, a concurrent review is required. When requesting services the Provider should submit the Member’s most recent Individualized Educational Plan (IEP) as developed by the local school department or the Individualized Service Plan (ISP) when applicable and the appropriate ABA and for Down Syndrome request form. In submitting the IEP, the Provider must seek the parents’ authorization to release that information from the school and not contact the school directly for that release.

4

4. The amount of hours or units of services authorized shall correspond to the severity and complexity of the member’s condition.

   Policy Guidelines and Definitions

   Documentation Required

   A. All authorization for treatment is based on documentation of medical necessity for specific treatment goals to address specific behavioral targets. The following is a guide to what is expected in individual treatment plans for members with Down Syndrome.

   B. Treatment plans must include:

5. Goals that relate to the core deficits of Down Syndrome and should be derived from the functional assessment and/or skills-based assessments that occur prior to initiating treatment.

6. Linkage and coordination with other behavioral health and medical providers who are concurrently providing services with the member/parent/guardian’s documented consent and available peer, community, and school based (Individualized Family Service Plan/IEP) providers.

7. Target dates for introduction of and mastery of the treatment goals.

8. Data from baseline levels for each identified goal.

9. Objective definitions of the behaviors targeted for increase or decrease.

10. Measurable data on progress toward the treatment goals.

11. Measurable definitions of the mastery criteria.

12. Parent/care-giver training goals. Any barriers to parent/care-giver participation must be documented.

13. A Transition Plan. If appropriate, the goals of a transition plan may include the level of supports a child needs in order to be successful when moving from one level of care to another, the skills the child is currently being taught to facilitate the transition, and the level of communication between the BCBA or Licensed Mental Health Clinician and any other related allied professionals such as the child’s teacher, speech therapist, occupational therapist, social worker, and or counselor. Transition plans may include several components depending on the child’s situation. A transition plan should be created when:

    a. The child begins treatment.

    b. The child is preparing to transition from a home-based intensive ABA-based program to a lesser level of care.

    c. The child is preparing to transition from a most to least restrictive environment placement.

5

d. The child is preparing to transition from a home-based ABA intervention program to a school- based program.

e. A transition plan should also address how the child will transition into adulthood.

10. Discharge Criteria must include requirements for discharge, discharge date, next level of care, and linkages with other services.

11. Behavioral Intervention Plan should be included if clinically necessary. Behavior plans should include a definition of the behavior, antecedents, consequences, prevention, baseline, and any de-escalation procedures.

12. Individualized steps for the prevention and/or resolution of crisis, (i.e. identification of crisis antecedents and consequences):

    a. Active steps or self-help methods to prevent, de-escalate, or defuse crisis situations.

    b. Names and phone numbers of contacts that can assist member in resolving crisis, such as other treatment providers that may assist in the prevention or de-escalation of behaviors, even for those members who do not currently display aberrant behaviors.

13. Supervision must be delivered to paraprofessional or BCBA level staff at the following level:

    a. A minimum of 90 minutes supervision per month is expected for each BCBA or paraprofessional. The maximum hours approved are based on the member’s direct hours, i.e., up to two (2) hours supervision for every 10 hours of direct service. Supervision may be a combination of group, individual, or in vivo modalities.

14. Parent/Guardian management skills that can be generalized to the home. It is required that parent goals and/or parent training is a part of each treatment plan.

    a. Document any assistance provided to caregivers or others to carry out the approved behavior support/maintenance plans.

    b. Provider observation of the caregivers or other plan implementers and the member’s behaviors to assess proper implementation of the behavior support/maintenance plan and interventions made based on those observations.

15. Incremental functional gains should be achieved not only during training sessions but between training sessions as well, demonstrating that the service is affecting clinical gains independent of direct contact with ABA clinicians, that the parents/primary care-takers are learning how to implement the treatment interventions.

16. Further it is expected that providers are continually monitoring a member’s progress in all areas of functioning. The treatment is expected to be modified as the parents/guardians management skills improve, and the member’s deficits are modified.

17. In the Concurrent Review include any updates to the crisis resolution plan outlined in the Initial Treatment Plan. Note any on-site assistance provided in difficult or possibly crisis situations.

6

18. Treatment Plan updates will be reviewed at a frequency as required by state-specific or account- specific requirements. The Treatment Plan update should reflect any major life changes and the member’s progress in the goals, objectives, and targets identified on the Initial Treatment Plan. In addition, new goals, objectives, and/or target behaviors should be added as indicated. Include how progress related towards transition or discharge plan. Graphs should be included to provide visual documentation of the member’s progress. Treatment planning is an expected part of member care.

    a. Submission of the treatment plan is expected at least 10 days prior to the next review date. Treatment plan updates that are not sent by the end of the authorization may result in claims being denied due to lack of an active authorization on file.

19. Documentation of the following information is always important and is essential when a member has made slow or no progress in the acquisition, maintenance and generalization of target skills.

    a. Assessments are completed as frequently as necessary to determine the relationship between environmental events and behaviors.

    b. Behavior support/maintenance plan noting changes based on ongoing assessments.

    c. Observe the member’s behaviors to determine effectiveness of the behavior support/maintenance plan and, if not effective, note changes to the plan.

    IV. What is Not Covered

    A. The following do not meet the medical necessity guidelines, and therefore coverage will not be authorized:

20. Therapy when measurable functional improvement is not expected or progress has plateaued.

21. Services that are primarily educational in nature.

22. Services encountered in school settings (e.g. psychosocial speech delay, behavioral problems, attention disorders, conceptual handicap, mental retardation, developmental delays). “Services related to Down Syndrome provided by school personnel pursuant to an individual education program are not subject to reimbursement”

23. Services that are not medically necessary.

24. Treatment whose purpose is vocationally or recreationally based.

25. Treatment that is investigational or unproven, including, but not limited to facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, Higashi (Daily Life Therapy).

26. Services that are provided for developmental purposes. For the purposes of this guideline the term developmental is defined as “a delay in the expected achievement of age-appropriate fine motor, gross motor, social, or language milestones that is not caused by an underlying medical illness or condition.”

7

8. Cognitive Therapy or retraining.

9. Personal training, life coaching

10. Custodial Care. For the purposes of this guideline custodial care is “care, administered by trained personnel, to whom the member shows no beneficial response despite extended and/or repeated treatment trials.”

    Coding Guidance

    ICD 10 Codes Description

    Q90-Q90.9 Down Syndrome

    CPT Codes Description PA 97151 Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non- face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan Yes 97152 Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face- to-face with the patient, each 15 minutes Yes 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes Yes 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes Yes 97155 Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes Yes 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes Yes 97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes Not
    Covered 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes Yes

    CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

    Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

8

References

The ABA coverage for Down Syndrome is provided consistently with the requirements in the state of Massachusetts beginning 1/1/2026, with coverage pursuant to Chapter 388 of the Acts of 2024.

https://www.cdc.gov/birth-defects/about/down-syndrome.html

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 8/2025 New Policy for 1/1/2026

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at the time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.