JOHNS HOPKINS HEALTHCARE

Transcription

1 Page 1 of 9 ACTION: New : Effective Date: 03/01/2013 Revising : Review Dates: 12/4/2015 Superseding : Archiving : Retiring : Johns Hopkins HealthCare (JHHC) provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. POLICY: For US Family Health Plan members, the following TRICARE criteria must be met to participate in the Comprehensive Autism Demonstration which is in effect from July 25, 2014 to December 31, Type 1 ABA: refers to narrowly targeted interventions for specific problematic behaviors I. When benefits are provided under the member s contract, JHHC considers Type 1 ABA medically necessary when all of the following are met: A. The benefits requested are not provided or have not already been provided for diagnostic or treatment services related to learning, curriculum planning, educational achievement or special education programs which are the responsibility of the educational system provided under the IDEA (IEP, IFSP) or 504 Plan, *AND; B. The initial treatment plan includes detailed goals of what specific behaviors will improve and by what percent within the proposed timeframe, AND; C. There must be a diagnosis** of a condition on the Autism Spectrum (ICD-10: F84.0 through F84.9) meeting all DSM-5 criteria AND; D. The member must be under the age of 18 (unless there are mandates specifying other age limits), AND; E. The maladaptive target behavior must be of a severity that the child s personal safety, or the safety of others in the child s environment, is jeopardized or very significantly or even completely interferes with ability to function, AND; F. Parent(s) (or guardians) are directly involved in prioritizing target behaviors and training in behavioral techniques so that they can provide additional hours of intervention, AND; G. There is a time-limited, individualized treatment plan developed that: 1. Is child-centered, strengths-specific, family-focused, community-based, multisystem, culturally-competent, and least-intrusive

2 Page 2 of 9 2. Clearly defines specific target behaviors 3. Records frequency, rate, symptom intensity or duration, or other objective measures of baseline levels 4. Establishes quantifiable criteria for progress 5. Describes: behavioral intervention techniques appropriate to the target behavior, reinforcers selected, and strategies for generalization of learned skills 6. Documents the plan for transition through the continuum of interventions, services, and settings, as well as discharge criteria, AND; H. Services must be provided directly or billed by individuals licensed by the state or certified by the Behavior Analyst Certifying Board, unless state mandates, plan documents or contracts require otherwise. Note ~ Qualified providers include: Board Certified Behavior Analyst (BCBA ), Board Certified Behavior Analyst Doctoral Designation (BCBA-D ) ABA services may only be reported by a licensed Behavior Analyst. It must be documented that services provided by a licensed assistant behavior analyst or behavior technician, (BT) are supervised by a licensed behavior analyst qualified as an ABA supervisor. These services may only be reported by the licensed behavior analyst for reimbursement. Note ~ All continued treatment plans for both Type 1 and Type 2 ABA must be submitted for reevaluation before the conclusion of the period that has been preauthorized or every three months, whichever is shorter. The treatment plan may require an evaluation from an independent practitioner with a specialty in ASD prior to submission if the evidence of necessity for further treatment is not clearly demonstrated by the submitted report prior to the conclusion of the period preauthorized. Note ~ All extended treatment plans for both Type 1 and Type 2 ABA require an evaluation from an independent practitioner with a specialty in ASD prior to submission at each six month interval. Type 2 ABA: refers to those broader behavioral interventions aimed at a wider range of skills building activities (usually applicable to behaviors that impair social interaction, communication, and adjustment to the environment). II. When benefits are provided under the member s contract, JHHC considers Type 2 ABA medically necessary when all of the following are met: A. The benefits requested are not provided or have not already been provided for diagnostic or treatment services related to learning, curriculum planning, educational achievement or special education programs which are the responsibility of the educational system provided under the IDEA (IEP, IFSP) or 504 Plan, * AND; B. The initial treatment plan includes detailed goals of what specific behaviors will improve and by what percent within the proposed timeframe, AND; C. There must be a diagnosis** of a condition on the Autism Spectrum (ICD-10: F84.0 through F84.9) meeting all DSM-5 criteria, AND;

3 Page 3 of 9 D. The member must be under the age of 18 (unless there are mandates specifying other age limits), AND; E. There are identifiable target behaviors having a SEVERE impact on development, communication, interaction with typically developing peers or others in the child s environment, or adjustment to the settings in which the child functions, such that the child cannot adequately participate in developmentally appropriate essential community activities such as school, AND; F. Parent(s) (or guardians) are directly involved in prioritizing target behaviors and training in behavioral techniques so that they can provide additional hours of intervention, AND; G. The ABA is not custodial in nature (which is defined as care provided when the member has reached the maximum level of physical or mental function and such person is not likely to make further significant improvement or any type of care where the primary purpose of the type of care provided is to attend to the member s daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel ). Plan documents may have variations on this definition and need to be reviewed, AND; H. There is a time limited, individualized treatment plan developed that: 1. Is child-centered, strengths-specific, family-focused, community-based, multisystem, culturally-competent, and least intrusive 2. Clearly defines specific target behaviors in terms of frequency, rate, symptom intensity or duration 3. Records objective measure of baseline levels 4. Establishes quantifiable criteria for progress 5. Describes behavioral intervention techniques appropriate to the target behavior, reinforcers selected, and strategies for generalization of learned skills 6. Plans for transition through the continuum of interventions, services, and settings, as well as discharge criteria, AND; I. Services are provided directly and billed by individuals licensed by the state or certified by the Behavior Analyst Certifying Board. Note ~ Qualified providers include: Board Certified Behavior Analyst (BCBA ), Board Certified Behavior Analyst Doctoral Designation (BCBA-D ). ABA services may only be reported by a licensed Behavior Analyst. It must be documented that services provided by a licensed assistant behavior analyst or behavior technician, (BT) are supervised by a licensed behavior analyst qualified as an ABA supervisor. These services may only be reported by the licensed behavior analyst for reimbursement. Note ~ All continued treatment plans for both Type 1 and Type 2 ABA must be submitted for reevaluation before the conclusion of the period that has been preauthorized or every three months, whichever is shorter. The treatment plan may require an evaluation from an independent practitioner with a specialty in ASD prior to submission if the evidence of necessity for further treatment is not clearly demonstrated by the submitted report prior to the conclusion of the period

4 Page 4 of 9 preauthorized. Note ~ All extended treatment plans for both Type 1 and Type 2 ABA require an evaluation from an independent practitioner with a specialty in ASD prior to submission at each six month interval. III. Unless specific benefits apply, JHHC considers all other types of ABA therapy not medically necessary. APPENDIX: * IDEA - Individuals with Disabilities Education Act (IEP - Individual Education Plan, IFSP - Individual Family Service Plan); 504 Plan - Section 504 of Rehabilitation Act of 1973, an antidiscrimination act. **Per CDC Screening and Diagnosis Guidelines, diagnosis must be made by at least one of the following: Primary Care Doctor Developmental Pediatrician Child Neurologist Child Psychologist or Psychiatrist ABA Provider Requirements: ABA Supervisor (BCBA, BCBA-D): Must possess a master s degree or above in a qualifying field as defined by the state licensure or certification requirements, or in the absence of existing state licensure or certification, a degree in a field accepted by the Behavior Analyst Certification Board (BACB) as meeting eligibility requirements for Board Certified Behavior Analyst (BCBA ) or (BCBA-D) certification. Basic Life Support (BLS), as demonstrated by BLS certification, BACB 8-hour online supervisory training course and competency for all BCBAs and BCBA-Ds providing supervision to any assistant behavior analyst or BT. In addition, possess the following credentials: 1. A current, unrestricted state-issued license to provide ABA if practicing in a state that offers licensure, OR 2. A current, unrestricted state-issued certificate as a provider of ABA if practicing in a state that does not offer licensure but offers certification, OR 3. A current certification from BACB as either a BCBA or a BCBA-D where such state-issued license or certification is not available, AND 4. Enter into a Participation Agreement with JHHC, AND 5. Meet all applicable requirements of the states in which they provide ABA, including those states in which they provide remote supervision of assistant behavior analysts and BTs and oversee ABA provided where the member is receiving services.

5 Page 5 of 9 Assistant Behavior Analyst: Must possess a bachelor s degree or above in a field as defined by the state licensure or certification requirements or in a field accepted by the BACB or Qualified Applied Behavior Analysis accreditation, (QABA ) as meeting eligibility requirements for assistant behavior analyst for states that do not regulate ABA. BLS, as demonstrated by BLS certification. In addition, have one of the following credentials: 1. A current, unrestricted State-issued license to provide ABA if practicing in a state that offers licensure; OR 2. A current, unrestricted State-issued certificate as a provider of ABA if practicing in a state that does not offer licensure but offers certification; OR 3. A current certification from BACB or QABA where such state-issued license or certification is not available. Assistant behavior analysts must receive supervision in compliance with the BACB or QABA rules and regulations. Only direct supervision, where the authorized ABA supervisor directly observes the assistant behavior analyst providing services with the member, will be reimbursed. Indirect supervision, to include but not limited to a review and discussion of case load, data collection procedures, and professional development, is not reimbursable. A supervised assistant behavior analyst working within the scope of their training, practice, and competence may assist the authorized ABA supervisor in various roles and responsibilities as determined appropriate by the authorized ABA supervisor and delegated to the assistant behavior analyst, consistent with the most current BACB Guidelines. Assistant behavior analysts must work under the supervision of an authorized ABA supervisor who meets the requirements specified above. Behavior Technician (BT): Para-professionals credentialed as Registered Behavior Technicians (RBT ) who meet the following educational requirements: 1. Have completed a minimum of 12 semester hours of college coursework in psychology, education, social work, behavior sciences, human development or related fields, such as counseling, OT, SLP, and be currently enrolled in a course of study leading to an associate or bachelor s degree by an accredited college or university, OR 2. Have completed a minimum of 48 semester hours of college courses in an accredited college or university in the above stated coursework, OR 3. Have obtained a High School diploma or General Education Development (GED) equivalent and have completed 500 hours of employment providing directly supervised ABA therapy as

6 Page 6 of 9 verified by the ACSP, or authorized ABA supervisor, AND BACKGROUND: Applied Behavioral Analysis (ABA) is defined in the 2011 Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review as an umbrella term describing principles and techniques used in the assessment, treatment, and prevention of challenging behaviors and the promotion of new desired behaviors. The goal of ABA is to teach new skills, promote generalization of these skills, and reduce challenging behaviors with systematic reinforcement. Within the Applied Behavioral Analysis (ABA) provider field, there is general recognition of two types of ABA. The terminology may vary among providers, however, and for the purpose of this document, Type 1 ABA will refer to narrowly targeted interventions for specific problematic behaviors. Type 2 ABA will refer to those broader behavioral interventions aimed at a wider range of skills building activities (usually applicable to behaviors that impair social interaction, communication, and adjustment to the environment). There may be overlap between these two types. Both methods utilize similar treatment techniques based on behavior modification, have the same theoretical underpinnings from the scientific literature on learning and behavior, and both are provided by professionals with similar training and credentials. CODING INFORMATION: CPT Copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member's specific benefit plan determines coverage and referral requirements. All inpatient admissions require preauthorization. PRE-AUTHORIZATION REQUIRED Compliance with the provision in this policy may be monitored and addressed through post-payment data analysis and/or medical review audits Employer Health Programs (EHP) **See Specific Summary Plan Description (SPD) Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply policy criteria US Family Health Plan (USFHP), TRICARE Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE, apply the Medical Policy Criteria

7 Page 7 of 9 CPT CODES 0359T 0360T 0361T 0364T 0365T 0368T 0369T 0370T 0362T 0363T 0366T DESCRIPTION CPT CODES COVERED WITH AUTHORIZATION Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report. Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient (List separately in addition to code for primary service) Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure) Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) CPT CODES NOT COVERED Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient (List separately in addition to code for primary procedure) Group adaptive behavior treatment by protocol, administered by technician, face-toface with two or more patients; first 30 minutes of technician time

8 Page 8 of T 0371T 0372T 0374T Group adaptive behavior treatment by protocol, administered by technician, face-toface with two or more patients; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in addition to code for primary procedure) REFERENCES STATEMENT: Analyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCare (JHHC) Medical Policy Team during the development and implementation of this medical policy. Per NCQA standards, the Medical Policy Team will continue to monitor and review any newly published clinical evidence and adjust the references below accordingly if deemed necessary. CLINICAL: 1. Hayes, Inc. (2014). Medical Technology Directory: Applied Behavior Analysis-Based Interventions for Autism Spectrum Disorder. Available: HEALTHPLAN: 2. CareFirst. (2014). Medical Policy Reference Manual: Autism Spectrum Disorders (Virginia Mandate), Operating Procedure 3.01/011A. Available: DBD85257D85006E446D?OpenDocument 3. Aetna. (2011). Applied Behavioral Analysis: Medical Necessity Guidelines for the Treatment of Autism Spectrum Disorders. Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Therapies for Children with Autism Spectrum Disorders. Available: _ pdf 4. BlueCross BlueShield. (2015). TEC Special Report: Early Intensive Behavioral Intervention and Other Behavioral Interventions for Autism Spectrum Disorder. Volume 30, No. 1. Available: 5. United Healthcare. (2014). Intensive Behavioral Therapy for Autism Spectrum Disorder. Available:

9 Page 9 of 9 US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Poli cies%20and%20protocols/medical%20policies/medical%20policies/intens_behav_thp y_tx_autism_spec_dis.pdf 6. Tufts Health Plan. (2013). Autism Professional Payment Policy. Available: REGULATORY: 7. Agency for Healthcare Research and Quality (AHRQ). (2014). Comparative Effectiveness Review: Therapies for Children with Autism Spectrum Disorders. Available: 8. Centers for Disease Control and Prevention. (2015). Autism Spectrum Disorders (ASDs): Screening and Diagnosis. Available: 9. TRICARE. (2012). Policy Manual M: Applied Behavioral Analysis (ABA). Chapter 7, Section 3.18.: TRICARE Policy Manual M: Applied Behavioral Analysis (ABA) 10. TRICARE. (2015) Operations Manual M February 1, 2008, Department Of Defense (DoD) Comprehensive Autism Care Demonstration: Chapter 18. : Department Of Defense (DoD) Comprehensive Autism Care Demonstration 11. COMAR (Maryland). Home and Community-Based Services Waiver for Children with Autism Spectrum Disorder ( ). Available: COMAR (Maryland). Utilization Review of Treatment for Autism and Autism Spectrum Disorders ( ):