Benefit Applications:

To determine the appropriate initial authorization of services for ABA, the following guidelines must be met. If any of the following conditions cannot be met, ABA therapy is considered not medically necessary:

1.     A diagnosis of Autism Spectrum Disorder (ASD) as defined by the current version of the American Psychiatric Association’s (APA) Diagnostic and Statistics Manual of Mental Disorders is documented as a current diagnosis[1] by a licensed psychiatrist or psychologist or pediatrician or neurologist or family practice with special training in treatment of Autism Spectrum Disorder (ASD); and

2.     A Functional Behavioral Assessment (FBA) has been completed by a licensed psychiatrist or psychologist or pediatrician or neurologist or family practice  or Board-Certified Behavior Analyst (BCBA) with special training in diagnosis of Autism Spectrum Disorder (ASD) within the past twelve months; and

3.     The individual specific treatment plan that includes, but is not limited to:

a.     Specific goals that have been identified as necessary based on behavioral, psychological, family, or medical concerns; and

b.     Measurable goals[2] that are objective in nature and measurable based on a standardized assessment[3] that is completed on a regularly documented basis by a licensed psychologist or psychiatrist; and

c.     A listing of the types of therapy that will be utilized during ABA sessions.  The following types of therapy are considered not medically necessary as a means of ABA therapy:

                                          i.    Activity Therapy (Example: Art, Music, or Dance Therapy)

                                         ii.    Pet Therapy (Example: Equine or Canine Therapy)

                                        iii.    Vision Therapy

                                        iv.    Secretin Infusion Therapy

                                         v.    Chelation Therapy

                                        vi.    Cognitive Rehabilitation

                                       vii.    Hippotherapy

                                      viii.    Sensory or Auditory Integration Therapy

                                        ix.    Manipulation Therapy

                                         x.    Biofeedback

                                        xi.    Neurofeedback

                                       xii.    Group Psychiatric Therapy

                                      xiii.    Nutrition or Dietary Therapy

d.     Specific outline of the location of each visit performed and the licensure or certification of the individual performing each visit[4].

4.     The documentation indicates that all individuals providing ABA services are licensed or certified. For any provider that is not a licensed psychologist or psychiatrist, such as a registered behavioral technician[5], copies of their certifications must be provided. 

To determine the appropriate continuing authorization of services for ABA, the following guidelines must be met. If any of the following conditions cannot be met, ABA therapy is considered not medically necessary:

1.     The individual has met and continues to meet all items listed under the initial authorization criteria; and

2.     The original individualized treatment plan has been updated based on the progression of the therapy; and

3.     Documentation displays:

a.     Standardized testing results that were documented in the initial treatment plan as the source of measurement for the goals outlined; and Interpretation of the testing results demonstrating the progression to date; and

b.     Interpretation of the testing results demonstrating the progression to date; and

c.     Updated individualized treatment plan documenting new anticipated timelines for previously outlined goals, presentation of new goals, and description of retired goals.

[1] Current diagnosis indicates that the member must have been seen within the past year for treatment of the disorder or as determined as appropriate by a Medical Director.

[2] Goals related to assisting the member with academic work or tutoring is not a benefit. Services related to creation or fulfillment of an IEP (Individualized Education Plan) is not a benefit. Services rendered in a school setting are not a benefit.

[3] Standardized assessments must include a baseline measurement, progress to date, and anticipated timeline

[4] Accompanying the patient to activities outside of the home (e.g. recreational activities, eating out, shopping, play activities, medical appointments), except when the patient has demonstrated a patient of significant behavioral difficulties during the specific activity is considered not a benefit.

[5] Registered Behavior Technicians are benefited if certified by BACB (Behavior Analyst Certification Board)