Treatment of Autism Spectrum Disorder (ASD)

POLICY NUMBER

L.8.01.403

DESCRIPTION

Autism spectrum disorder (ASD) represents complex disorders of brain development characterized by variable social interaction and communicative deficits with repetitive, restricted behaviors and for many, significant cognitive impairment. The autism spectrum symptomatology is characterized by impaired social interaction, problems with verbal and nonverbal communication, and unusual, repetitive, or severely limited activities and interests. ASD, as defined in the fifth Edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes disorders previously referred to as:

• Atypical autism

• Asperger's disorder

• Childhood autism

• Childhood disintegrative disorder aka Heller’s Syndrome

• Early infantile autism

• High-functioning autism

• Kanner's autism

• Pervasive developmental disorder not otherwise specified

Asperger syndrome is a milder form of ASD. Childhood disintegrative disorder is a rare form of Autism. Rett syndrome is diagnosed almost exclusively in females and may be misdiagnosed primarily as autism. Rett syndrome is no longer listed as autism in the DMS-5. However, a child may have dual Rett and ASD diagnoses.

The National Institute of Mental Health indicates that ASDs are reliably diagnosed by the age of 3 and can be diagnosed as early as 18 months of age. Parents are usually the first to recognize the child’s unusual behavior or development. All children should have routine developmental exams by their pediatrician during their well child visits. Further testing may be initiated if there is concern on the part of the doctor or parents. This is particularly true whenever a child fails to meet any of the following language milestones:

• Babbling by 12 months

• Gesturing (pointing, waving bye-bye) by 12 months

• Single words by 16 months

• Two-word spontaneous phrases by 24 months (not just echoing)

• Loss of any language or social skills at any age.

The American Academy of Pediatrics recommends routine ASD screening at 18 and 24 months, and surveillance at every visit. Refer to the Preventive Health Services Medical Policy.

There is no single treatment for ASD. It is reported that early diagnosis and treatment results in improved outcomes for those diagnosed with ASD. Early intensive behavioral intervention (EIBI) is a therapy based on Applied Behavioral Analysis (ABA) proposed as an effective intervention for children with ASD. ABA is not the appropriate treatment for every Member and parents should be counseled that ABA is not curative. The goals of this treatment are to improve communication, cognitive skills, social interaction, and adaptive behavior. Educational interventions include both behavioral and habilitative strategies concentrating on the development of communication skills, socialization skills, adaptive skills, and control or ablation of disruptive behaviors.

Board Certified Behavior Analysts (BCBA® and BCBA-D®) are credentialed by the Behavioral Analyst Certification Board. Typically, they are unlicensed by many states. They use positive reinforcement and other principles to build communication, play, social, academic, self-care, work, and community living skills, and to reduce problem behaviors in learners with autism. ABA techniques involve highly structured individual instruction where skills are broken down into small steps or components, and learners are provided many repeated opportunities to learn and practice skills in a variety of settings, with abundant positive reinforcement. The goals of intervention as well as the specific types of instructions and reinforcers used can be customized to the strengths and needs of the individual learner. Performance is measured continuously by direct observation, and intervention is modified if the data show that the learner is not making satisfactory progress.

This Medical Policy recognizes that research, of varying quality, shows that ABA provides a positive effect on improvement of intelligence/cognitive skills and communications skills in certain young children, at least, over a short period of time. Research to determine the efficacy of ABA continues as well as research regarding the criteria for ABA participation, its intensity, duration and lasting benefit. This Medical Policy is designed to provide individualized structured coverage while awaiting additional evidenced based studies.

Related medical policies are –

• Speech Therapy

• Preventive Health Services

• Genetic Testing for Rett Syndrome

• Genetic Testing for Developmental Delay/Intellectual Disability, Autism Spectrum Disorder, and/or Congenital Anomalies

• Genetic Testing for FMR1 Mutations (including Fragile X Syndrome)

• Cognitive Rehabilitation

• Hippotherapy

• Sensory Integration Therapy and Auditory Integration Therapy

• Chelation Therapy for Off-Label Uses

• Hyperbaric Oxygen (HBO) Pressurization

• Immunoglobulin Therapy

POLICY

Medically Necessary Treatment for Autism Spectrum Disorder

I. Applied Behavioral Analysis

A. Applied Behavioral Analysis (ABA) is considered medically necessary for the treatment of autism spectrum disorder (ASD) if ALL of the following criteria are met:

1. Confirmed ASD Diagnosis - A licensed physician (M.D./D.O.) or licensed psychologist has diagnosed the Member with ASD having met all of the following DSM-5 criteria:

a. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifests deficits: 1) in social-emotional reciprocity; 2) in nonverbal communicative behaviors used for social interaction; and, 3) in developing and maintaining relationships; AND,

b. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1) stereotyped or repetitive speech, motor movements, or use of objects; 2) excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; 3) highly restricted, fixated interests that are abnormal in intensity or focus; and/or 4) hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; AND,

c. Symptoms must be present in early childhood (although may not fully manifest until social demands exceed capacity); AND,

d. Symptoms together limit and impair every day functioning.

2. Referral for ABA Assessment - A referral for authorization of ABA assessment must be submitted by a licensed physician (M.D./D.O.) or a licensed psychologist for Members meeting the diagnostic criteria referenced in A.1.

3. ABA Assessment by a Certified Practitioner

a. Behavioral identification assessment and observational behavioral follow-up assessments [97151, 97152] must be provided or supervised by a licensed therapist (BCBA or BCBA-D) certified by the nationally accredited Behavior Analyst Certification Board.

i. Behavioral identification assessment [97151] is considered medically necessary once every six months. The initial assessment must be performed within four to six hours and completed within three days of beginning the assessment. This service must be provided by a BCBA or BCBA-D.

ii. Observational behavioral follow-up assessments [97152] are considered medically necessary for a maximum of three hours every six months, as needed. These services must be provided by the following:

1. A BCBA, or

2. A BCBA-D, or

3. A Board Certified Assistant Behavioral Analyst (BCaBA) who is supervised by a BCBA or BCBA-D, or

4. A Licensed Board Certified Registered Behavior Technician (RBT) who is supervised by a BCBA or BCBA-D.

b. Exposure behavioral follow-up assessments [0362T] are considered medically necessary for a maximum of three hours every six months, as needed. Exposure behavioral assessments must be provided or supervised by a BCBA or BCBA-D. Documentation of BCBA or BCBA-D onsite supervision must be provided for exposure behavioral follow-up assessments.

4. ABA Treatment Plan Development – An individualized specific treatment plan is developed by a BCBA or BCBA-D and includes all of the following:

a. Focus on and addressing the identified behavioral, psychological, family and medical concerns of the Member; and,

b. The goals of intervention are appropriate for the Member’s age and impairment status (in keeping with the applicable Member’s health plan benefits and/or exclusions). Social, communication, or language skills or adaptive functioning that have been identified as deficient according to age expected norms form the foundation for the individualized specific treatment plan, including hours of therapy; and

c. Identification of measurable goals in objective and measurable terms based on standardized autism-specific testing [such as Assessment of Basic Language and Learning Skills (ABLLS), Verbal Behavior Milestones Assessment and Placement Program (VBMAPP), or comparable test) that addresses the behaviors and deficiencies for which the ABA intervention is to be applied. Each goal should reflect baseline measurements, progress intervals measurements and anticipated and updated timeline for achievement of the goals over the course of treatment;

• Standardized autism-specific testing (ABLLS, VBMAPP, or comparable test) [96112, 96113] must be done within two months of the beginning of the initial course of treatment for baseline measurements of social skills, communication skills, language skills and adaptive functioning

d. Type, amount, duration and frequency of treatment are included in the individualized specific treatment plan; and,

e. The treatment plan is to be shared with the Member’s Primary Care Provider and referring provider, if different from the ordering provider.

5. Provision and Supervision of ABA Assessment, Treatment, and Treatment Plan Revision

a. Individual, group, and family adaptive behavior treatment [97153, 97154, 97156, 97157, 97158] is considered medically necessary according to the Member's individualized specific treatment plan.

Individual and group adaptive behavior treatment by protocol must be provided by the following:

1. A BCBA, or

2. A BCBA-D, or

3. A BCaBA who is supervised by a BCBA or BCBA-D, or

4. A Licensed Board Certified RBT who is supervised by a BCBA or BCBA-D.

Family adaptive behavior treatment by protocol must be provided by a BCBA, BCBA-D, or a Board Certified Assistant Behavioral Analyst (BCaBA) supervised by a BCBA or BCBA-D.

b. Two hours of adaptive behavior treatment with protocol modification [97155] may be considered medically necessary to modify a treatment plan for every 10 hours of therapy, as needed. These services must be provided by a BCBA, BCBA-D or BCaBA who is supervised by a BCBA or BCBA-D.

c. Exposure adaptive behavior treatment with protocol modification [0373T] may be considered medically necessary to modify a treatment plan three hours every two months, as needed. These services must be provided or supervised by a BCBA or BCBA-D. Documentation of BCBA or BCBA-D onsite supervision must be provided for exposure adaptive behavior treatment.

Refer to the Applied Behavioral Analysis (ABA) Coding Policy.

B. Continuation of ABA is considered medically necessary only if there is documented evidence of clinical progress toward treatment plan goals with interim assessment (97151) at least every six months and meet ALL of the requirements below. The re-assessment must be performed within two to four hours and completed within three days of beginning the re-assessment.

1. The Member met the criteria for the initial course of ABA; and,

2. There is an order for continuation of ABA treatment from the licensed physician (M.D./D.O.) or licensed psychologist in A.2. above; and,

3. The individualized specific treatment plan is updated no less than every six months or more often based on the Member’s specific situation; and,

4. The updated treatment plan includes measures of the progress made with social skills, communications skills, language skills and adaptive functioning. Clinically significant progress in these skills are to be documented as follows:

a. Interim progress assessment at least every six months based on clinical progress of the treatment plan goals;

b. Developmental status as measured by standard scores using standardized autism-specific testing (ABLLS, VBMAPP, or comparable test) [96112, 96113] performed by a developmental pediatrician, child psychiatrist, or child psychologist once per year; and,

5. The updated individualized specific treatment plan includes age and deficiency appropriate goals and measurements of progress. As during the initial course of treatment, the following must be documented for each goal:

a. Include standardized autism-specific testing (ABLLS,VBMAPP, or comparable test) measurements of social skills, communication skills, language skills and adaptive functioning; and,

b. Progress interval measurements; and,

c. Anticipated and updated timeline for achievement of the goals over the course of treatment based on initial and subsequent assessments.

* A Member’s progress is to be measured using standardized autism-specific testing (ABLLS, VBMAPP, or comparable test) with known normative data. Such tests should have age specific norms against which the Member’s progress is measured. The norms and the Member’s results must be clearly documented in the record.

II. Speech Therapy, Physical Therapy, and Occupational Therapy

Speech Therapy, Physical Therapy, and Occupational Therapy are considered medically necessary for the treatment of ASD, if rendered in accordance with the Member’s specific benefit plan for the treatment of the co-morbidities of ASD, and the therapy rendered is considered the standard of care for the co-morbid condition diagnosed by the treating physician under a therapy treatment plan outlining the goals of therapy, mode of therapy, and duration of therapy. In addition, the requirements of the Speech Therapy Medical Policy must be met.

Not Medically Necessary and Investigational Treatment for Autism Spectrum Disorder

ABA treatment is considered not medically necessary when the criteria above are not met or when there is no documentation of clinically significant developmental progress in any one of the following areas: social skills, communication skills, language skills, or adaptive functioning as measured by either a) interim progress assessment or b) developmental status as measured by standardized autism specific testing (ABLLS, VBMAPP, or comparable test).

The following are considered investigational treatment for ASD:

• Activity therapy, such as music, dance, art or play therapies

• Pet Therapy

• Vision Therapy

• Secretin Infusion Therapy

• Chelation Therapy

• Cognitive Rehabilitation

• Hippotherapy

• Hyperbaric Oxygen Therapy

• Intravenous Immune Globulin

• Sensory or Auditory Integration Therapy

• Gastrointestinal (GI) Function/Health Panel

• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

• Elimination Diet

• Spinal Manipulation

• Biofeedback

• Neurofeedback

POLICY EXCEPTIONS

Self-Funded Groups (unless specified)

Federal Employee Program (FEP) Members: Effective 01/01/2017, ABA Assessment and Treatment may be covered for FEP Members with no age restrictions or visit limits subject to the Prior Authorization, Medical Necessity, and Assessment requirements of the Medical Policy guidelines. Benefits are available for Standard Option, Basic Option, and Blue Focus Members. For Blue Focus Members, benefits for ABA for treatment of ASD are limited to 200 hours per person, per calendar year. Standard Option Members may receive services from Non-Network Behavior Analyst Certification Board certified practitioners.

State Health Plan (State and School Employees): The Medical Policy guidelines are effective for State Health Plan Participants effective 07/01/2015. Effective 08/01/2024, submission of the individualized ABA treatment plan for approval by the Company is no longer required for State Health Plan Participants.

Effective 08/01/2024, submission of the individualized ABA treatment plan for approval by the Company is no longer required for Fully-Insured Members or Self-Funded Group Members with benefits available for the treatment of ASD.

POLICY GUIDELINES

Refer to the Applied Behavioral Analysis (ABA) Coding Policy.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Benefits will not be provided for the following:

• Custodial care

• Day-care

• Respite, shadow, paraprofessional, or companion services

• Personal training, life coaching, or job coaching

• Services that are primarily academic or educational in nature regardless of setting

• Any programs, including educational, required by federal or state law to be performed and/or offered by public schools, including, but not limited to, Individualized Education Programs, Special Education Services, and Individuals with Disabilities Education Improvement Act programs, Attention Deficit Disorder Classrooms; Autism Spectrum Disorders Classrooms or Applied Behavioral Analysis (ABA)

• Treatment for autism spectrum disorders not covered under Medical Policy unless mandated by state law

• Speech Therapy and Physical Medicine (Physical and Occupational Therapy) visits in excess of the Schedule of Benefits

• Services/treatment excluded under the Member’s Benefit Plan.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B. appropriate with regard to standards of good medical practice; and

C. not solely for the convenience of the Member, his or her Provider; and

D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

03/16/2015: New policy added. Approved by Medical Policy Advisory Committee.

06/26/2015: Policy statement updated to clarify which codes are appropriate for ABA assessment and treatment and the level of supervision required. The VABS, ADOS, and CARS developmental tests were replaced with the ABLLS and VBMAPP tests. The Policy Exceptions section was updated regarding State Health Plan members to state that the policy is effective for State Health Plan members as of 07/01/2015.

08/31/2015: Medical policy revised to add ICD-10 codes.

05/27/2016: Policy number L.8.01.403 added.

12/22/2016: Policy Exceptions section updated for FEP Members and Hood Container - Union and Non-Union Self-Funded Group.

12/12/2017: Policy reviewed and updated to add when services can be provided by a Licensed Board Certified Registered Behavior Technician (RBT) who is supervised by a Network BCBA or Network BCBA-D.

01/15/2018: Policy reviewed and updated to remove the following requirements for ABA therapy: 1) member age limit of 8 years and 2) treatment limit of three years. Effective 01/15/2018.

05/29/2018: Medical policy link updated in policy description.

12/20/2018: Policy statements and Code Reference section updated to add new 2019 CPT codes 96112, 96113, 97151, 97152, 97153, 97154, 97155, 97156, 97157, and 97158. Removed deleted codes from policy statements. Revised code descriptions for CPT codes 0362T and 0373T, effective 01/01/2019.

09/16/2019: Policy statement revised to state that two hours of adaptive behavior treatment with protocol modification [97155] may be considered medically necessary to modify a treatment plan for every 10 hours of therapy. It previously stated that three hours every two months were considered medically necessary.

11/01/2019: Policy Guidelines revised to eliminate Benefits exclusion for Home based care and School settings. Policy Guidelines revised to provide there are no Benefits for respite, shadow, paraprofessional, companion services, personal training, life coaching and/or job coaching. Policy Guidelines revised to provide there are no Benefits for services which are primarily academic and/or educational in nature, regardless of setting.

03/24/2020: Medically necessary criteria regarding behavioral identification assessment updated to add that the initial assessment must be performed within four to six hours and completed within three days of beginning the assessment. Medically necessary statement regarding continuation of ABA updated to add that the re-assessment must be performed within two to four hours and completed within three days of beginning the re-assessment. Added the following temporary policy statement: Effective March 16, 2020, through April 30, 2020, the requirement to provide a re-assessment (CPT 97151) prior to the expiration of the previously approved individualized specific treatment plan is waived. The Member’s previously approved individualized specific treatment plan is extended through May 31, 2020. Code Reference section updated to remove deleted CPT codes 0359T, 0360T, 0361T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0374T, and 96111.

04/14/2022: Policy Exceptions updated to remove Hood Container - Union and Non-Union Self-Funded Group Members. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

01/01/2023: Policy reviewed. Policy section updated to remove the Network Provider requirement for BCBAs, BCBA-Ds, and BCaBAs. Policy Exceptions updated regarding FEP members with FEP Blue Focus.

12/08/2023: Policy reviewed; no changes.

07/30/2024: Policy updated to remove Prior Authorization requirements for Fully-Insured and Self-Funded Group Members and State Health Plan Participants effective 08/01/2024.

03/11/2025: Policy reviewed; no changes.

09/10/2025: Removed Network provider requirements for ASD diagnosis and referral for ABA assessment. Removed this language regarding parent/caregiver participation in the plan of care: The parent(s) or caregiver(s) must participate fully and follow training and provide support which is incorporated into the individualized specific treatment plan. Removed public school therapy hours from the 25 hours a week maximum.

10/15/2025: Policy statement updated to state ABA treatment [97153, 97154, 97156, 97157, 97158] is considered medically necessary according to the Member's individualized specific treatment plan. Removed the maximum of 25 hours a week.

SOURCE(S)

1. UptoDate® - Autism spectrum disorder in children and adolescents: Behavioral and educational intervention

2. Blue Cross and Blue Shield of Florida Treatment of Autism Spectrum Disorders Medical Policy and its sources.

3. Anthem Blue Cross and Blue Shield Applied Behavioral Analysis for Autism Spectrum Disorder Medical Policy and its sources.

4. Arkansas Blue Cross and Blue Shield Autism Spectrum Disorder, Early Behavioral Intervention Medical Policy and its sources.

5. Report to the Mississippi Legislature, “Evaluation of Health Insurance Coverage for the Treatment of Autism Spectrum Disorders”, November 25, 2014.

6. National Autism Center’s National Standards Project 2009

7. http://www.cdc.gov/ncbddd/autism/hcp-dsm.html

8. http://www.cdc.gov/ncbddd/childdevelopment/documents/screening-chart.pdf

9. http://sfari.org/news-and-opinion/viewpoint/2012/in-defense-of-childhood-disintegrative-disorder

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

{{red:The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.}}

Medically Necessary Codes

Not Medically Necessary Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.