JOHNS HOPKINS HEALTHCARE

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1 Page 1 of 5 ACTION: New Policy Revising Policy Number Superseding Policy Number Archiving Policy Number Retiring Policy Number Johns Hopkins HealthCare 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, before carrying out any form of treatment or service. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. POLICY: For US Family Health Plan members see TRICARE Policy Manual M August 1, 2002, Applied Behavioral Analysis (ABA): Chapter 7, Section 3.18 and TRICARE Policy Manual M, February 1, 2008, Special Education: Chapter 9, Section 9.1. For Priority Partners, refer to Value Options for coverage determination. For EHP see the following criteria. Applied Behavior Analysis (ABA) When benefits are provided under the member s contract, JHHC considers Type 1 ABA medically necessary when all of the following are met: The initial treatment plan includes detailed goals of what specific behaviors will improve and by what percent within the proposed timeframe, AND; There must be a diagnosis* of a condition on the Autism Spectrum (ICD10 F84.0 through F84.9) and the member must be under the age of 18 (unless there are mandates specifying other age limits), AND; 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;

2 Page 2 of 5 Parent(s) (or guardians) must be involved in training in behavioral techniques so that they can provide additional hours of intervention, AND; There is a time limited, individualized treatment plan developed that: Is child-centered, strengths-specific, family-focused, community-based, multi-system, culturally-competent, and least intrusive Clearly defines specific target behaviors Records frequency, rate, symptom intensity or duration, or other objective measures of baseline levels Establishes quantifiable criteria for progress Describes: behavioral intervention techniques appropriate to the target behavior, reinforcers selected, and strategies for generalization of learned skills Documents the plan for transition through the continuum of interventions, services, and settings, as well as discharge criteria, AND; There is involvement of community resources to include at a minimum, the school district if the child is 3 or older, or early intervention, if not. AND; 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. When benefits are provided under the member s contract, JHHC considers Type 2 ABA medically necessary when all of the following are met: The initial treatment plan includes detailed goals of what specific behaviors will improve and by what percent within the proposed timeframe, AND; There must be a diagnosis* of a condition on the Autism Spectrum (ICD10 F84.0 through F84.9) and the member must be under the age of 18 (unless there are mandates specifying other age limits), AND; 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; Parent(s) (or guardians) must be involved in prioritizing target behaviors, and training in behavioral techniques so that they can provide additional hours of intervention. AND;

3 Page 3 of 5 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; There is a time limited, individualized treatment plan developed that: Is child-centered, strengths-specific, family-focused, community-based, multi-system, culturally-competent, and least intrusive Clearly defines specific target behaviors in terms of frequency, rate, symptom intensity or duration Records objective measure of baseline levels Establishes quantifiable criteria for progress Describes behavioral intervention techniques appropriate to the target behavior, reinforcers selected, and strategies for generalization of learned skills Plans for transition through the continuum of interventions, services, and settings, as well as discharge criteria, AND; There is involvement of community resources to include at a minimum, the school district if the child is 3 or older, or early intervention, if not, AND; Services are provided directly and billed by individuals licensed by the state or certified by the Behavior Analyst Certifying Board. Note ~ All continued treatment plans for both Type 1 and Type 2 ABA must be submitted for reevaluation at a minimum of every six months. Unless specific benefits apply, JHHC considers all other types of ABA therapy investigational as they do not meet TEC criteria #2-5. *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 Providers of therapy must be state licensed as well as BACB and ABA certified.

4 Page 4 of 5 CROSS REFERENCE: Applied Behavioral Analysis (ABA), TRICARE Policy Manual M, February 1, 2008, Chapter 7, Section 3.18, Issue Date: August 10, DISCUSSION: 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, but in this document, Type 1 ABA will refer to narrowly targeted interventions for specific problematic behaviors (the severe end of the spectrum described in the first sentence of this paragraph) and 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 some overlap between these, and both 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 2013 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. Please see EHP, Priority Partners, and/or US Family Health Plan Outpatient Referral Guidelines for Pre-Authorization Requirements. All inpatient admissions require preauthorization. Compliance with the provision in this policy may be monitored and addressed through post-payment data analysis and/or medical review audits

5 Page 5 of 5 Employer Health Programs (EHP) **See Specific Summary Plan Description (SPD) then apply policy criteria CPT CODE None HCPCS CODE None DESCRIPTION DESCRIPTION Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply policy criteria US Family Health Plan (USFHP), please refer to most recent approved TRICARE Medical Policy Manual. TRICARE Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE then apply the Medical Policy Criteria HISTORY: New Policy REFERENCES: 1. Aetna. Applied Behavioral Analysis. Medical Necessity Guidelines for the Treatment of Autism Spectrum Disorders. (2010). Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Therapies for Children with Autism Spectrum Disorders. [cited 10/14/2011]; Available from: care.ahrq.gov/ehc/products/ 106/656/CER26_Autism_Report_ pdf 2. Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Therapies for Children with Autism Spectrum Disorders. [cited 10/14/2011]; Available from: pdf 3. Centers for Disease Control and Prevention, Autism Spectrum Disorders (ASDs), Screening and Diagnosis. (2012). Approval Signature: Chester W. Schmidt Jr., M.D. Date: 03/01/2013 Chester W. Schmidt Jr., M.D. Chief Medical Officer, Johns Hopkins HealthCare, LLC Chairman, Medical Policy Committee