Clinical Guideline Coverage Criteria

The Plan considers ABA therapy visits and/or Habilitative care visits after a comprehensive evaluation and with a referral (as needed) as reasonable and medically necessary for Autism Spectrum Disorder when ALL of the following are met:

1. Member has a definitive diagnosis of an Autism Spectrum Disorder from a Neurologist, Pediatric Neurologist, Developmental Pediatrician, Psychologist, Psychiatrist, or other licensed physician experienced in the diagnosis and treatment of autism; and
2. The diagnostic evaluation includes, without limitation, behavioral and cognitive evaluation, prenatal (if known) and perinatal history, developmental history, and medical screening for comorbid medical issues; and
3. From initial evaluation through the entire course of treatment, ALL of the following must be met and documented in the rendering Provider’s medical record:
   • Contemporaneous progress notes signed by the rendering Provider must include the procedure, participants, setting, content of therapeutic intervention, time, and date of each session; and
   • 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 diagnosis are active, resulting in substantial impairment in daily functioning; and
   • Communication with Member’s primary care physician (PCP) and other treating professionals is reflected in the medical record; and
   • There is a clear treatment plan with measurable goals that address the signs and symptoms of the diagnosis; and
   • There is no less intensive or more appropriate level of services which can be safely and effectively provided; and
   • Member’s condition can be classified with at least one of the diagnosis codes listed below; and
   • Parent(s) and/or guardian(s) involvement in the training of behavioral techniques must be documented in Member’s medical record and is critical to the generalization of treatment goals to Member’s environment; and
   • ABA services are provided by a Board-Certified Behavior Analyst (BCBA) or paraprofessional (H2019) supervised by a BCBA and are billed with the procedure codes listed below; and
   • Habilitative services, including group treatment, are provided by a licensed health care provider providing services within the scope of his/her professional license and are billed with standard billing codes.

Limitations

The Plan considers ABA therapy for Autism Spectrum Disorder as not medically necessary for the following:

1. Services that are primarily educational in nature
2. “Services related to autism spectrum disorder provided by school personnel pursuant to an individual education program are not subject to reimbursement” 3
3. Treatment that is investigational or unproven, including, but not limited to facilitated communication, Auditory Integration Therapy (AIT), Holding Therapy, Higashi (Daily Life Therapy)
4. Personal training or life coaching