“Aetna considers Applied Behavior Analysis (ABA) experimental, investigational, or unproven for Down Syndrome in the absence of an autism spectrum disorder (ASD) co-morbidity because of insufficient evidence in the peer-reviewed literature.

Aetna considers ABA experimental, investigational, or unproven for all other non-ASD indications because of insufficient evidence in the peer-reviewed literature.”

1. The individual has met the criteria above for initial or continuing treatment; and
2. The treatment plan should include treatment with a certified or licensed physician, qualified healthcare provider, or ABT technician (in accordance with state law and benefit plan requirements) for 40 hours per week or less;
   and
   Note: ABT services for more than 40 hours per week have not been shown to be more effective and documentation as to why more than 40 hours per week is planned must be provided.

3. A certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements) provides protocol modification; and
4. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours requested for each behavioral target. The total hours of ABT requested should be comprised of 40 hours per week or less.”

• individual meets criteria for ASD in the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5 Text Revision [TR]) services are appropriate in terms of type, frequency, extent, site and duration
• treatment is being provided by an appropriate behavioral health care professional
• meaningful and measurable improvement is expected from the therapy”

1. Essential elements are met.
2. There is demonstration of functional impairment on a standardized scale of functioning in the past 12 months. For instance, the Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior Assessment Scale (ABAS), VB-MAPP or ABLLS. The impairment must be at least one standard deviation below the population mean OR represent a significant risk of harm to self or others.
3. Parent(s) (or guardians) will be provided necessary support and training to reinforce interventions and generalize gains.
4. The level of impairment (calculated below) justifies the number of hours requested.

Medical necessity criteria to continue applied behavior analysis

All the following criteria must be met:

1. Essential elements are still met.
2. Re-evaluation of interventions and progress has been performed (every six months) to assess the need for ongoing ABA; AND a repeated validated assessment (e.g., Vineland, ABAS, VB-MAPP or ABLLS) has been done every 6–12 months to demonstrate response to intervention.
3. The frequency of the target behavior has improved since the last review, or if not, there has been modification of the treatment, additional assessments have been conducted, and/or there has been appropriate consultations from other staff or experts.

4. Parent(s) (or guardians) will have measurable goals that work to reinforce interventions and generalize gains across multiple settings and allow progress to be maintained over time as the treating professional fades out.
5. The treatment plan documents a gradual tapering of higher intensities of intervention and a shifting to supports from other sources (school, as an example) as progress occurs.
6. The level of impairment (calculated using the Assessment of Symptom Severity above) justifies the number of hours requested for ABA.

1. The member has had a documented diagnostic assessment and final diagnosis of an autism spectrum disorder (ASD) by:
   1. a qualified Kaiser Permanente provider or multi-disciplinary team appropriately licensed and trained in the diagnosis and treatment of autism; or
   2. a qualified non-Kaiser Permanente provider whose evaluation and diagnosis has been reviewed and confirmed by a qualified Kaiser Permanente provider or multi- disciplinary team appropriately licensed and trained in the diagnosis and treatment of autism; AND

2. There is documentation of a severe challenging behavior and/or communication and social interaction issues, clearly related to characteristics of ASD that:
   1. presents a health or safety risk to self or others (such as self-injury, aggression toward others, destruction of property, elopement, severe disruptive behavior); OR
   2. presents a significant functional interference within the home and/or community; AND
   3. demonstrates behaviors that are developmentally inappropriate and pose a significant obstacle to the member’s performance of developmentally appropriate daily functioning including self-help and communication
3. There is a reasonable expectation on the part of a qualified treating practitioner or multi-disciplinary team that the individual’s behavior will improve significantly with ABA therapy.”

1. Determination of medical necessity is not based on severity rating of diagnosis. However, the norm or criterion referenced skills assessment(s) must demonstrate clinically significant deficits (two standard deviations below the average score range; developmental functioning significantly below expected functioning for chronological age); AND
2. Additional skills based/criterion referenced skills assessments, such as the Assessment of Basic Language and Learning Skills (ABLLS), Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) if desired for program development; (checklists or curriculums may be used as supplements but should not be used as stand-alone measures as they do not yield a result that establishes the presence of age- or developmental stage-based clinically significant deficits); AND
3. The member’s primary caregivers agree to actively participate in the ABA treatment process; AND
4. The intensity of treatment is not more than the member is able to tolerate, remain engaged, and physically available to receive; AND

5. In accordance with practice guidelines, a formal treatment plan has been developed with all the “Critical Features of a Treatment Plan” including:
   • The proposed treatment by type; and
   • ABA treatment history, duration, and other therapies/community-based resources the member is accessing; and
   • Demographic information, educational and vocational settings; and
   • The frequency of the proposed treatment, transition, and discharge criteria; and
   • The anticipated duration of the treatment; and
   • Current (within 30 days of submission of the formal treatment plan) standardized norm referenced skills assessment that measures the symptoms associated with a diagnosis of Autism (e.g., Vineland Adaptive Behavior Scales 3); and
   • The estimated dates of mastery stated in individualized goals; AND
6. Goals should include baseline dates, data, current dates, data, and graphs (within 30 days of submission of the formal treatment plan), for maladaptive behavior; AND
7. Objectives that are measurable and tailored to the patient; AND
8. The interventions emphasize generalization of skills and focus on the development of spontaneous social communications, adaptive skills, and appropriate behaviors; AND
9. The interventions are consistent with ABA techniques to be performed by licensed and/or ABA certified/State Licensed Behavior Analysts (LBA) provider; and if applicable
10. An individual acting under the supervision of a qualified ABA Provider; AND
11. Parent or caregiver training and support is incorporated into the treatment plan as measurable goals; and
    • Parent or caregiver training and support includes generalization of interventions via goals previously mastered by technicians in safe and analog settings, generalization of settings via community-based homework between parent training sessions and/or determination of the function of problem behavior or skill deficit analysis in the community, attended by parent/caregiver(s) and Board-Certified Behavior Analyst (BCBA)/program supervisor only.”

CPT codes: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T

• Current level (baseline)
• Behavior parent/caregiver is expected to demonstrate, including condition under which it must be demonstrated and mastery criteria (the objective or goal)
• Date of introduction
• Estimated date of mastery
• Specify plan for generalization
• Report goal as met, not met, modified and include explanation

1. ASD specific developmental evaluation;
2. Cognitive and adaptive behaviors evaluations;
3. Speech, language and comprehensive communication evaluation by speech-language pathologist;
4. Formal audiological hearing evaluation including frequency-specific brainstem auditory evoked response
5. Measurement of blood lead level if the child exhibits developmental delay and pica, or lives in a high-risk environment additional periodic lead screening can be considered if the pica persists;

6. Genetic testing specifically high resolution chromosome analysis (karyotype) and DNA analysis for fragile X syndrome in the presence of mental retardation (or if mental retardation can not be excluded) if there is a family history of fragile X or mental retardation of undetermined etiology, or if dysmorphic features are present
7. Comparative genomic hybridization (CGH), when medical necessity criteria are met in;
8. Medical evaluation (complete medical history and physical examination, including neurologic evaluation);
9. Parent and/or child interview (including siblings of children with autism);
10. Quantitative plasma amino acid assays to detect phenylketonuria;
11. Selective metabolic testing if the child exhibits any of the following:
    1. Clinical and physical findings suggestive of a metabolic disorder:
       1. Cyclic vomiting, recurrent vomiting and dehydration
       2. Early seizure
       3. Lethargy
       4. Hearing impairment
       5. Hypotonia
       6. Visual impairment
       7. Unusual odor; or
    2. Dysmorphic or coarse features; or
    3. Evidence of mental retardation or mental retardation can not be ruled out; or
    4. Occurrence or adequacy of newborn screening for a birth defect is questionable;
12. Genetic counseling for parents of a child with autism;
13. Electroencephalogram (EEG) for clinical spells that might represent seizures;
14. Physical therapy (PT) and/or occupational therapy (OT) evaluations for sensorimotor deficits;
15. Sleep-deprived EEG study only if the child exhibits any of the following conditions:
    1. Clinical seizures; or
    2. High suspicion of subclinical seizures; or
    3. Symptoms of developmental regression (clinically significant loss of social and communicative function) at any age, but especially in toddlers and pre-schoolers;
16. Video-EEG when criteria are met;
17. Pharmacotherapy for management of co-morbidities;

Note: Coverage of pharmacotherapy is subject to the member’s specific benefits for drug coverage. Please check benefit plan descriptions for details. Information on pharmacotherapy options for autism can be found in the Background section below.

18. Behavior modification, for management of behavioral co-morbidities;

Note: Interventions for behavioral co-morbidities are covered under the member’s behavioral health benefits. Please check benefit plan desecriptions for details.

19. Intensive educational interventions [see Footnote1* below] in which the child is engaged in systematically planned and developmentally appropriate educational activity toward identified objectives, including services rendered by a speech-language pathologist to improve communication skills;

[Footnote1]* Notes:

1. Many Aetna plans exclude coverage of educational services. For example, speech therapy or ABA services during class would be excluded under these plans. Please check benefit plan exclusions;
2. There is insufficient evidence for the superiority of any particular intensive educational intervention strategy (such as applied behavior analysis or other behavioral approaches, educational approaches such as structured teaching (e.g., Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH)), social-relational approaches (e.g., Developmental, Individual-differences, Relationship-based (DIR) therapy (DIR floortime therapy), Relationship Development Intervention (RDI) model) or developmental models (e.g., Early Start Denver Model (ESDM)) over other intensive educational intervention strategies.;

20. Alternative and augmentative communication aids (e.g., sign language, flashcards, communication boards, etc.) if demonstrated as effective for the individual with PDD;

Note: Some plans exclude coverage of “communication aids.” Please check benefit plan exclusions.

21. Physical and occupational therapy for co-morbid physical impairments;
22. Medical therapy or psychotherapy, as indicated for co-morbid medical or psychological conditions

Note: Psychotherapy is covered under the member’s behavioral health benefits. Please check benefit plan descriptions.”

1. Agency responsible for implementation, location of service delivery, and number of referred service hours necessary to effectively address the challenging behaviors and skill acquisition goals
   • If re-authorization is being requested, utilization of hours for most recent authorization should be included.
2. Background information (i.e., identifying information, primary reason for services, and current levels of functioning) and case history (i.e., medical, family, social, and educational information)
3. Assessments completed for evaluation, treatment plan implementation, maintenance and generalization plan, and discharge plan

4. FBA, Functional Analysis (when available), operational definitions, baselines, and specific Treatment Goals that include frequency, intensity, and duration data, and mastery criteria
5. Behavior intervention plan for each behavior targeted for decrease, including antecedent and consequence interventions, and descriptions of how barriers are being addressed
6. Skill Acquisition Goals and Objectives (Appendix B) that are in the social, communication, cognitive, adaptive, and vocational domains. Goals and Objectives should be measurable (see TERMINOLOGY Section), implement evidence-based interventions (see Section 3.12 Preferred Evidence Based Practices Section), tailored to the individual, include baseline measurement levels and present levels of performance, address barriers, and include changes to the plan if limited or no progress has been made across multiple skills or regression has occurred, and an anticipated timeline for mastery
7. Parent/Caregiver Training Goals including baseline measurement levels, present levels of performance, address barriers and include changes to plan if limited or no progress has been made, and an anticipated timeline for mastery.
8. A selection of programs and targets based on the functioning level of the individual, degree of behavior management required, and the time available to run programs
9. Coordination of care with other service providers
10. Crisis management plan for medical and behavioral emergencies
11. Plan for transition including how services will be faded and next level of care
12. Plan for discharge including quantitative criteria for discharge and reasons for discharge
13. Medical and behavioral crisis management plan”

1. Validated developmental and adaptive skills assessment (i.e., ABAS or Vineland,) to establish baseline functioning.
2. Review of the recipient’s medical, psychiatric, educational records.
3. An evaluation of the purpose of maladaptive behaviors using a validated assessment tool (e.g., QABF, FAST, FACT).
4. Caregiver interview.
5. Evidence of coordination of services with the recipient’s other treatment providers.
6. Consideration for the recipient’s medications and medical comorbidities.
7. A detailed description of behavior reduction goals with clear definition, antecedent, baseline, and mastery criteria for needed skills development.
8. A detailed description of replacement behavior and skill acquisition goal selection based on reported behaviors and developmental evaluation scores.
9. Caregiver training goals and a plan to provide necessary support and training to caregivers as well as a plan to evaluate their acquisition of these skills.
10. A detailed proposal for the intensity and duration of services, as well as the locations where those services will be provided.
11. Full documentation of any IEP services the recipient is receiving and a description of how the proposed care will coordinate with the established IEP.
12. An indication of other services that will be necessary such as physical therapy or family therapy, and documentation that such referrals have been provided.
13. A clear plan with objective milestones for the systematic reduction of care and the criteria for discharge from services.”