Humana Applied Behavior Analysis Form
This procedure is not covered
Description
Applied behavior analysis (ABA) is a type of therapy that focuses on improving specific behaviors, such as social skills, communication, adaptive learning skills, activities of daily living and school or job competence, while minimizing negative behaviors. ABA can be used to teach new skills, facilitate maintaining certain behaviors or to help transfer skills and behaviors learned in one situation or setting to another. Autism is the most common indication for ABA, with most research on the clinical utility of ABA pertaining to autism spectrum disorder (ASD).
According to the Behavior Analyst Certification Board (BACB), ABA has four core characteristics:
- An objective assessment and analysis of an individual’s condition by observing how the environment affects the individual’s behavior, as evidenced through appropriate data collection
- Importance is 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 to improve an individual’s health, independence, and quality of life
- Consistent, ongoing, objective assessment and data analysis to inform clinical decision-making
These core components facilitate the identification of behaviors that interfere with normal developmental processes. Understanding the relationship between a behavior and the individual’s environment allows those behaviors to be modified, thereby improving the individual’s functional capacity.
Techniques used may include chaining, or breaking a task down to its smallest parts; prompting, or encouraging the individual to respond appropriately; fading, or using less intrusive prompts to bring about a desired result until prompting is no longer needed; shaping, or gradually modifying inappropriate behaviors; and finally, providing varying levels of either positive or negative reinforcement, depending on the task or behavior targeted.
Treatment may vary from one individual to another in terms of the complexity and range of treatment goals, intensity and duration of treatment, and the amount of direct treatment provided. Behavior analysts rely on direct observation and data from other assessments, such as academic, medical or social.
The BACB operates certification programs that credential and recognize practitioners at three levels:
- Board Certified Behavior Analyst (BCBA)
- Board Certified Assistant Behavior Analyst (BCaBA)
- Registered Behavior Technician (RBT)
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
BCBAs with doctoral training, may receive the designation of Board Certified Behavior Analyst – Doctoral (BCBA-D), but this is not a separate certification, nor does it grant practice status above or beyond BCBA; both are behavior analysts.
While the BACB establishes practice standards, administers examinations, and provides ethics requirements and a disciplinary system for each of its certification programs, state law governs the certification, licensure or registration requirements for the various levels of ABA providers.
For information regarding non-ABA related diagnosis and treatment of ASD, please refer to Autism Spectrum Disorders Diagnosis and Treatment Medical Coverage Policy.
Coverage Determination
Any state mandates for applied behavior analysis (ABA) take precedence over this medical coverage policy.
Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.
Assessment for ABA Treatment
Humana members may be eligible under the Plan for assessment for ABA treatment when the following criteria are met:
- Autism spectrum disorder (ASD) has been diagnosed per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) or DSM-5, Text Revision (DSM-5-TR) diagnostic criteria for ASD by a licensed medical professional or other qualified health care professional as is consistent with state licensing requirements; AND
- Documentation that supports ASD diagnostic criteria is met (e.g., Autism Diagnostic Interview-Revised [ADI-R], Autism Diagnostic Observation Schedule-2 [ADOS-2], medical records, school records); AND
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
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Comprehensive ABA assessment completed by a Board Certified Behavior Analyst (BCBA), or other duly certified, licensed or registered equivalent provider (as defined by state law), which includes the following components:
- Complete developmental history, including comorbidities, current medications, hearing and vision evaluation; AND
- Evaluation of current functioning in areas to be treated by ABA, (e.g., adaptive and functional behavior, communication/language, social skills, etc.)
using reliable and valid standardized assessment tools*; ANDo Includes caregivers, family and other individuals**, as well as cultural or language considerations that may impact treatment
Initial ABA Treatment
Once authorized, initial treatment includes development of the individualized treatment plan and the first 180 days of therapy.
Humana members may be eligible under the Plan for initial ABA treatment when the following criteria are met:
- All services provided are within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided; AND
- Evidence from the assessment that the individual has the ability to participate in and benefit from the proposed ABA treatment with measurable improvements in the domains established in the treatment plan; AND
- Individualized treatment plan is developed by a Board Certified Behavior Analyst (BCBA), or other duly certified, licensed or registered equivalent provider (as defined by state law), based on the findings obtained from the comprehensive ABA assessment and addresses the following:
- Specific behaviors and skills targeted for improvement; AND
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 5 of 14
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o Specific treatment settings (eg, community, home, school, work) compatible with the individual’s needs and abilities; AND
o Baseline data obtained for all target behaviors and skills across all treatment settings (eg, community, home, school, work); AND
o Establishes clearly defined, measurable goals for improving target behaviors and skills; AND
o Describes data collection procedures; AND
o Continues quantification and analysis of direct observational data on behavioral targets during treatment and follow-up to maximize and maintain progress toward treatment goals; AND
o Utilizes data and direct assessments to adjust the treatment plan; AND
o Provides for coordination with and training of caregivers, family and other individuals**; AND
o Includes measurable goals for caregivers, family and other individuals** to ensure their ability to continue the established behavioral intervention in the home and community; AND
o Contact with the client and caregivers (direct supervision) accounts for a minimum of 50 percent of the case supervision time; AND
o Treatment planning and supervision by a Board Certified Behavior Analyst (BCBA), or other duly certified, licensed or registered equivalent provider (as defined by state law), follows the general standard of care of 2 hours for every 10 hours of direct treatment; AND
o Includes clearly defined, measurable discharge criteria and transition plan across all treatment settings
*Examples of standardized assessment tools include, but may not be limited to: Adaptive Behavior Assessment System Third Edition (ABAS-3), Assessment of Basic
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
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Language and Learning Skills Revised (ABBLS-R), Assessment of Functional Living Skills (AFLS), Autism Treatment Evaluation Checklist (ATEC), Community-based Skill Assessment (CSA), Functional Assessment Screening Tool (FAST), Gilliam Autism Rating Scale-3 (GARS-3), Scales of Independent Behavior Revised (SIB-R), Social Responsiveness Scale Second Edition (SRS-2), Social Skills Improvement System SSIS Rating Scales (SSIS), Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), Vineland Adaptive Scales Third Edition (Vineland-3), or the most current edition of any of the above. **The term 'other individuals' includes childcare providers, government services staff, health care providers, teachers/school personnel and any adult stakeholder who is involved in reinforcing behavioral interventions established in the individualized treatment plan.
Continuation of ABA Treatment
Commercial Plan members: all requests for continuation of ABA therapy require medical necessity review every 180 days.
Humana members may be eligible under the Plan for continuation of ABA treatment when the initial criteria were met and ALL of the following:
- Individual (and data collected) shows improvement and progress toward established goals; AND
- Treatment plan has been updated regularly to provide status of previously established goals or creation of new goals; AND
- Evidence of improvement is demonstrably measurable by reliable and valid standardized assessment tools*; AND
- Individual as well as caregivers, family and other individuals** continue to actively and proficiently participate in the treatment plan
Coverage Limitations
Humana members may NOT be eligible under the Plan for any of the following:
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 7 of 14
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Assessment for ABA without a diagnosis of autism spectrum disorder (ASD) or when the assessment criteria are not met
- Continuation of ABA when measurable progress toward established goals is no longer occurring (individual is regressing or plateauing) or when the above criteria are not met
- Greater than 40 hours of ABA per week
This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
Humana members may NOT be eligible under the Plan for ABA assessment or treatment for any indications other than those listed above including, but may not be limited to, the following:
- Cognitive decline; OR
- Dementia; OR
- Down syndrome; OR
- Substance abuse; OR
- Traumatic brain injury (TBI)
This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
Background
Additional information about applied behavior analysis (ABA) or autism spectrum disorder (ASD) may be found from the following websites:
- American Academy of Child and Adolescent Psychiatry
- American Academy of Pediatrics
- National Clearinghouse on Autism Evidence and Practice
- National Institute of Mental Health
- National Library of Medicine
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 8 of 14
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Medical Alternatives
Alternatives to ABA include, but may not be limited to, the following:
- Cognitive behavioral therapy
- Prescription drug therapy
Physician consultation is advised to make an informed decision based on an individual's health needs.
Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 9 of 14
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
97154
Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes
97155
Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes
97156
Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157
Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158
Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes
CPT® Category Ill Code(s)
Description
0362T
Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 10 of 14
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
0373T
15 minutes of technicians’ time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior.
Code(s)
Description
HO031
Mental health assessment, by nonphysician
HO032
Mental health service plan development by nonphysician
H2012
Behavioral health day treatment, per hour
H2019
Therapeutic behavioral services, per 15 minutes
References
- American Academy of Child & Adolescent Psychiatry (AACAP). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder (ARCHIVED). https://www.aacap.org. Published February 2014. Accessed January 20, 2023.
- American Academy of Pediatrics (AAP). Clinical Report. Identification, evaluation and management of children with autism spectrum disorder. https://www.aap.org. Published January 2020. Accessed January 20, 2023.
- American Psychiatric Association (APA). Autism spectrum disorder. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association; 2013:50-59.
- American Psychiatric Association (APA). DSM-5-TR Fact Sheet.
- Autism Spectrum Disorder. https://www.psychiatry.org. Published 2022. Accessed January 26, 2023.
- Association of Professional Behavior Analysts (APBA). Clarifications regarding applied behavior analysis treatment of autism spectrum disorder: practice guidelines for healthcare funders and managers. https://www.apbahome.net. Published February 2019. Accessed January 20, 2023.
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 11 of 14
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- ClinicalKey. Bennett AE, Fishbein LB. Applied behavioral analysis for autism spectrum disorder. In: Feldman HM, Elias ER, Blum NJ, Jimenez ME, Stancin T. Developmental-Behavioral Pediatrics. 5th ed. Elsevier; 2023:912-922. https://www.clinicalkey.com. Accessed January 19, 2023.
- Council of Autism Service Providers (CASP). Applied behavior analysis treatment of autism spectrum disorder: practice guidelines for healthcare funders and managers, 2nd ed. https://www.casproviders.org. Published 2014. Accessed January 24, 2023.
- ECRI Institute. Hotline Response. Intensity of applied behavior analysis in children. https://www.ecri.org. Published December 5, 2019. Accessed January 19, 2023.
- ECRI Institute. Hotline Response (ARCHIVED). Applied behavior analysis for treating older children, adolescents and young adults with autism spectrum disorder. https://www.ecri.org. Published August 11, 2014. Updated January 18, 2018. Accessed January 19, 2023.
- Hayes, Inc. Health Technology Assessment. The Early Start Denver Model for treatment of autism spectrum disorder. https://evidence.hayesinc.com. Published August 6, 2019. Updated August 31, 2022. Accessed January 19, 2023.
- Hayes, Inc. Medical Technology Directory. Comparative effectiveness review of intensive behavioral intervention for treatment of autism spectrum disorder. https://evidence.hayesinc.com. Published March 13, 2019. Updated February 10, 2022. Accessed January 19, 2023.
- MCG Health. Applied behavior analysis. 26th edition. https://www.mcg.com. Accessed December 19, 2022.
- UpToDate, Inc. Autism spectrum disorder in children and adolescents: behavioral and educational interventions. https://www.uptodate.com. Updated January 2022. Accessed January 24, 2023.
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 12 of 14
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Appendix A – DSM-5 or DSM-5-TR Criteria for Autism Spectrum Disorder
Severity is based on social communication impairments and restricted, repetitive patterns of behavior. (see Table 2)
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, not exhaustive; see text):
- 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.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
- 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.
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, not exhaustive; see text):
- Stereotyped or repetitive motor movements, use of objects, or speech (eg, simple motor 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).
- Highly restricted, fixated interests that are abnormal in intensity or focus (eg, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
- Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (eg, apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
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Revision Date: 03/01/2023
Review Date: 03/01/2023
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C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
Specify current severity:
TABLE 2 Severity levels for autism spectrum disorder
| Severity level | Social communication | Restricted, repetitive behavior |
|---|---|---|
| Level 3 | Severe deficits in verbal and nonverbal | Inflexibility of behavior, extreme |
| Requiring very substantial | social communication skills cause severe | difficulty coping with change, or |
| support | impairments in functioning, very limited | other restricted/repetitive |
| initiation of social interactions, and minimal | behaviors markedly interfere with | |
| response to social overtures from others. | functioning in all spheres. |
TABLE 2 Severity levels for autism spectrum disorder (cont'd)
| Severity level | Social communication | Restricted, repetitive behavior | |
|---|---|---|---|
| Level 1 | Requiring support | Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear 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 is able to speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful. | Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. |
Applied Behavior Analysis Effective Date: 03/01/2023
Revision Date: 03/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0587-004 Page: 14 of 14
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.