Autism spectrum disorders (ASD)

are a group of neurodevelopmental disorders characterized by difficulties in social interaction, impaired communication (both verbal and nonverbal), and repetitive, restrictive behaviors that present in early childhood. ASD has heterogeneous etiology and comorbidities. Diagnostic criteria and nomenclature for these disorders have changed over the years and, while the current terminology in the Diagnostic and Statistical Manual 5 (DSM 5) uses a single category called Autism Spectrum Disorders, previous versions divided this into multiple subcategories.

Early Intensive Behavioral Intervention (EIBI):

A well-developed scientific discipline among the helping professions that focuses on the analysis, design, implementation, and evaluation of social and other environmental modifications to produce meaningful changes in human behavior. It includes the use of direct observation, measurement, and functional analysis of the relations between environment and behavior. It uses changes in environmental events, including antecedent stimuli and consequences, to produce practical and significant changes in behavior.

Types of behavioral interventions include, but are not limited to:

• direct services from a team of specialists providing home- based Early Intensive Behavioral Intervention,
• Assessments and treatment planning,
• Parent training,
• Consultation and training for early intervention staff,
• Co-visits with Early Intensive (EI) professionals,
• Parental and caregiver involvement in the process and continued use of the strategies outside of the formal sessions is important for the success of the treatment in the long-term.

Point32Health companies6615527Early Intensive Behavioral Intervention1EIBI is typically an intensive treatment program for children 0-3 years of age, designed to address challenging behaviors as defined in the admission criteria. It is not a center-based program. It can only occur in settings that are natural or typical for a same age infant or toddler without a disability. Natural settings may include home or community settings. Community settings are Childcare centers, childcare homes, libraries, parks.

Clinical Guideline Coverage Criteria

Admission of Early Intensive Behavioral Intervention Services

1. The Member has a referral from an Early Intervention Provider (EIP); and
2. If required, EIBIs obtain a Prior Authorization to conduct an assessment. (In most cases, EIBIs do not need to wait until the family has selected a specific provider to obtain the Prior Authorization for the assessment); and
3. The child must have a confirmed diagnosis of Autism Spectrum Disorder (ASD), conferred by a physician or licensed psychologist allowing children to get started with services as soon as possible. It is preferred that the diagnosis be made using a diagnostic tool and that the DSM-V criteria are referenced in the diagnostic evaluation summary

Continuation of Early Intensive Behavioral Intervention Services

1. The individual's condition continues to meet admission criteria for EIBI, either due to continuation of presenting problems, or appearance of new problems or symptoms; and
2. There is reasonable expectation that the individual will benefit from the continuation of EIBI services. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated.

The treatment plan is updated based on treatment progress including the addition of new target behaviors; and

1. Initial assessment from a BCBA, LABA with the request for EIBI services;
2. A Member's progress is monitored regularly evidenced by behavioral graphs, progress notes, and daily session notes.
3. The treatment plan is to be modified, if there is no measurable progress toward decreasing the frequency, intensity and/or duration of the targeted behaviors and/or increase in skills for skill acquisition to achieve targeted goals and objectives;
4. There is documented skills transfer to the individual and treatment transition planning from the beginning of treatment;
5. Services must be written on the IFSP and consented to by the family;
6. Services are not duplicative of services that are part of an Individual Educational Plan (IEP) or Individual ServicePlan (ISP).

Discharge from Early Intensive Behavioral Intervention Services

The Plan considers discharge from early intensive behavioral intervention services as reasonable and medically necessary when ONE of the following is met:

1. A Member’s individual treatment plan and goals have been met; or
2. The individual has achieved adequate stabilization of the challenging behavior, and less-intensive modes of treatment are appropriate and indicated; or
3. The individual no longer meets admission criteria or meets criteria for a less or more intensive service; or
4. The child turns 3 years of age and has been transitioned to the Local Educational Agency (LEA) for services; or
5. Treatment is making the symptoms persistently worse; or
6. The individual is not making progress toward treatment goals, as demonstrated by the absence of any documented meaningful (i.e., durable and generalized) measurable improvement or stabilization of challenging behavior, and there is no reasonable expectation of progress.

Limitations

The Plan considers early intensive behavioral intervention services are not medically necessary for ANY of the following:

1. The individual has medical conditions or impairments that would prevent beneficial utilization of services.
2. The individual requires the 24-hour medical/nursing monitoring or procedures provided in a hospital setting.
3. The following services are not included within the EIBI treatment process and will not be certified:

• vocational rehabilitation
• supportive respite care
• recreational therapy
• respite care

The services are primarily for school or educational purposes.

The treatment is investigational or unproven, including, but not limited to facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, and Higashi (Daily Life Therapy).

Codes

The following code(s) are associated with these services For the purposes of this Medical Necessity Guideline, the Plan will require the use of the following diagnosis code(s)

• Code
• Description

Please note that the following codes apply to Harvard Pilgrim Health Care Commercial and Tufts Health Plan products only

• 97151-TL - Behavior identification assessment, administered by physician or other qualified healthcare professional, 15 mins
• 97152-TL - Behavior identification assessment by technician, 15 mins
• 97155-TL - Adaptive behavior treatment with protocol administered by physician or other qualified healthcare professional, 15 mins
• 97153-TL - Adaptive behavior treatment by technician, 15 mins
• 97154-TL - Group adaptive behavior treatment protocol technician, 15mins
• 97158-TL - Group adaptive behavior with protocol administered by physician or other qualified healthcare professional, 15 mins
• 97156-TL - Family adaptive behavior treatment guidance administered by physician or other qualified healthcare professional, 15 mins
• 97157-TL - Multiple - family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional, 15 mins
• 0362T-TL - Behavior identification supporting assessment, each 15 mins of technician time face to face with a patient, requiring the following components, administered by the physician or other qualified health professional who is on site, with the assistance of two or more technicians, for a patient who exhibit destructive behavior, completed in an environment that is customized to the patient's behavior
• 0373T-TL - Adaptive behavior treatment with protocol modification ,each 15 mins of technician time face to face with a patient, requiring the following components, administered by the physician or other qualified health professional who is on site, with the assistance of two or more technicians, for a patient who exhibits destructive behavior, completed in an environment that is customized to the patient's

Behavior identification supporting assessment, each 15 mins of technician time face to face with a patient, requiring the following components, administered by the physician or other qualified health professional who is on site, with the assistance of two or more technicians, for a patient who exhibits destructive behavior, completed in an environment that is customized to the patient's behavior

Please note that the following codes apply to Tufts Health Together and Direct products only.

• H2019-TL - Therapeutic behavioral services, per 15 minutes (Direct instruction by a paraprofessional working under the supervision of a licensed professional.)
• H2012-TL - Behavioral health day treatment, per hour (Direct instruction by a licensed professional/parent training for home services by a licensed professional.)
• H0031-TL - Mental health assessment, by nonprofessional (Assessment and case planning for home services by a licensed professional. 15-minute rate.)

3 Early Intensive Behavioral Intervention3

• 10032-TL - Mental health service plan development by nonphysician (Supervision for home services by a licensed professional. 15-minute rate.)

• 7156-TL - Family adaptive behavior treatment guidance, administered by a licensed professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), every 15 minutes