Clinical Policy Title: Applied behavior analysis (ABA)

Clinical Policy Title: Applied behavior analysis (ABA) Clinical Policy Number: 11.04.03 Effective Date: October 1, 2015 Initial Review Date: May 15, 2015 Most Recent Review Date: June 17, 2015 Next Review Date: May 2016 Related policies: CP# 11.04.02 Genetic testing for autism spectrum disorder Policy contains: Applied behavior analysis (ABA). Early intensive behavioral intervention (EIBI). Early Start Denver Model (ESDM). Autism. ABOUT THIS POLICY: AmeriHealth Caritas District of Columbia has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas District of Columbia clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by AmeriHealth Caritas District of Columbia when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas District of Columbia clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas District of Columbia clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas District of Columbia will update its clinical policies as necessary. AmeriHealth Caritas District of Columbia clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas District of Columbia considers applied behavior analysis (ABA) to be clinically proven and, therefore, medically necessary when the following criteria are met: A. Eligibility criteria Child carries diagnosis of autism spectrum disorder documented through a structured assessment. Treatment initiated prior to age 8 years, zero months. Continued treatment requires reassessment every six months. 1

Continued treatment up to 36 months after initiation of treatment. Individuals outside the above criteria will be evaluated case by case based on evidence of medical necessity. B. Provider requirements Provider holds a doctoral degree in clinical psychology, counseling psychology, school psychology or another applied health service area of psychology. Provider has at least two years of experience in a supervised health service setting in which one year of experience was obtained in an organized health service training program and at least one year of experience was obtained after the individual received the individual's doctoral degree in psychology. Provider complies with continuing education requirements of the state in which the provider is licensed. If available within state-based access standards, the provider must be certified by the Behavioral Analyst Certification Board (BACB). C. Treatment criteria A treatment plan must be submitted and followed with renewal every six months. The treatment plan must focus on behavioral goals. Therapeutic intervention duration must be age-appropriate and individualized: For children under age 3 years, 25 to 30 hours per week. For children over age 3 years, 30 to 40 hours per week. No additional benefit or coverage for more than 40 hours per week. NOTE: There are insufficient evidence based studies on the use of ABA for child less than 36 months of age. Treatment plan sets behavioral goals, and addresses and records progress in: Communications. Social and family interaction. Harmful behaviors. Continued treatment must include: Measurement of progress using recognized instruments. Continued progress toward goals. Provider submitting documentation of progress upon request. Limitations: Therapy services such as occupational therapy, physical therapy and speech therapy, when incorporated into the ABA treatment plans, must have documentation of medical necessity and be included in plan benefits. 2

Applied behavior analysis may be reviewed case by case for evidence of medical necessity in children under age 21 years who do not meet the criteria in this coverage policy. Applied behavior analysis is not clinically proven and not a plan benefit for adults ages 21 and over, or for individuals with other behavioral health disorders. Applied behavior analysis is not a plan benefit when used for educational achievement. All other uses of ABA and early intensive behavioral intervention (EIBI) are not medically necessary. NOTE: The following codes are not included in the Medicaid medical fee schedule in the District of Columbia: 0359T - 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 0360T - 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 0361T - 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 0362T - 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 0363T - 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 0364T - Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time 0365T - Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time 0366T - Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time 3

0367T - Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time 0368T - 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 0369T - 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 0370T - Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) 0371T - Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) 0372T - Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients 0373T - Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient 0374T - 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-toface with patient Alternative covered services: Alternative treatment includes medication, family counseling, standard behavioral health visits and medically necessary institutional care. Background Although the quality of clinical evidence is moderate to low, ABA or behavioral treatment is the only treatment that has been determined to be well-established and efficacious in the treatment of children diagnosed with autism spectrum disorders according to the Chambliss Criteria used to evaluate the degree of published empirical support for psychosocial interventions. ABA involves discrete-trial teaching, breaking skills down into their most basic components, rewarding the demonstration of appropriate behavior with praise and positive reinforcement, and then "generalizing" skills in a naturalistic setting (LeBlanc & Gillis, 2012). ABA is the design, implementation and evaluation of environmental modifications to produce socially significant improvement in human 4

behavior (BACB 2012). Generalization to the setting where behaviors naturally occur is an essential component of ABA (BACB 2012). A specific type of intensive ABA, EIBI, is the treatment that has the strongest empirical support. At very young ages, 40 hours per week resulted in 47 percent of participants achieving the best outcome when compared with only 2 percent in the control group (Lovaas, 1987). The definition of best outcome is IQ in the normal range and a full-inclusion first-grade placement with symptoms so mild that these children were indistinguishable from their peers. In the past 10 years, this study has been replicated by many others (Eikeseth, Smith & Jahr, 2002; Howard, Sparkman, Cohen, et al., 2005; Smith, Groen and Wynn, 2000; Sallows and Graupner, 2005). EIBI is an expensive treatment when delivered at the level that achieves optimal results, although savings will likely be obtained in the future through the avoidance of higher levels of care and/or custodial services for older children, adolescents and adults. Thus, a long-term view of overall health and functional ability requires consideration of this approach for appropriate candidates. Assessment:Impairment due to autism spectrum disorders (ASDs) must be documented through structured assessment, and limit the child s ability to perform functional activities of daily living or participate in public school-based educational systems. All children must have baseline structured assessments (e.g., ADOS or STAT) with follow-up assessments completed for concurrent review. Treatment plan must include goals specific to observed behaviors. The following information is required for all initial and concurrent reviews and must be related to the individual needs of the member: Selection of interfering behavior or behavioral skill deficit. Identification of goals and objectives. Establishment of a method of measuring target behaviors. Evaluation of the current levels of performance (baseline). Design and implementation of the interventions that teach new skills and/or reduce interfering behaviors. Continuous measurement of target behaviors to determine the effectiveness of the intervention. Ongoing evaluation of the effectiveness of the intervention, with modifications made as necessary to maintain and/or increase the effectiveness and the efficiency of the intervention. Treatment:Options and methods ABA treatment has important characteristics that should be apparent throughout treatment: An objective analysis of the individual s condition by observing the relationship of the environment to the individual s behavior, as reflected through detailed data collection. An understanding of the context of the behavior and its value to the individual and the environment. 5

Applications of the principles and procedures of behavior analysis in concert with the health and well-being of the individual. Treatment outcomes that are socially relevant and meaningful for the child. Treatment plan expectations (include parents role as well as what should be included and how it is used): Strengths-based. Family-centered. Goals are SMART (Strengthening Mental Abilities with Relational Training) Includes caregiver training and transfer of skills. A focus on problems in the following areas: o Cognitive functioning. o Pre-academic skills. o Safety skills. o Social skills. o Play and leisure skills for community integration. o Vocational skills. o Coping and tolerance skills. o Adaptive and self-help skills. o Language and communication. o Attending and social referencing. o Reduction of interfering and inappropriate behaviors. Treatment protocols:the following characteristics should be evident in all phases of assessment, diagnosis and treatment: Specific levels of baseline behavior defined when developing treatment goals Treatment directed at establishing small units or behavior targets, which build up to larger and more significant changes in functioning. Detailed data collection on behavioral targets to measure progress toward treatment goals. It must be measurable and obtained from direct observational data analysis. Functional behavior assessment (FBA). There must be an understanding of the function of the behaviors being treated. A functional assessment of undesirable behaviors is critical because most problem behaviors serve a purpose and are reinforced by their consequences. Examples are (1) to gain attention, (2) to avoid an undesirable request or situation, and (3) engaging in a particular activity or obtaining a particular object. Behavior intervention plan (BIP). A BIP uses information gathered from the FBA. The BIP outlines a plan for decreasing the frequency of the behavior. Treatment environment(s) maintained to minimize problematic behaviors. A carefully designed individualized and detailed behavior analytic treatment constructed that uses evidence-based behavior analytic treatment methods. 6

Frequent direct assessment, analysis and adjustments to the treatment plan based on the individual s progress. This should be determined by observable and measurable data analysis. Treatment protocols implemented frequently in various environments until the individual can function in a variety of situations. Family members, a key component of the program, provided support and training to promote and maintain improvements in behavior. They should be involved in all decisions on programming for the child. Supervision. The ABA program should be designed and monitored by a board-certified behavior analyst or licensed behavioral health clinician who ensures that strategies are appropriately implemented. This is especially important for parents with newly diagnosed children. Sustainability of treatment approach: o Queues for parents to know when to access follow-up help. o Boosters. Methods Searches (April 2015): AmeriHealth Caritas District of Columbia searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidencebased practice centers. The Centers for Medicare & Medicaid Services (CMS). Search were conducted on April 24, 2015, using the terms applied behavior analysis, autism spectrum disorders and early intensive behavioral intervention. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings: 7

ASD has proved to be highly prevalent, with one in 68 school-age children having this diagnosis. Multiple treatments have been attempted with none having an overall success. ABA, EIBI and similar techniques have low to moderate level of evidence to demonstrate effectiveness. But studies have failed to show the effectiveness of ABA for older children or adults, or for continuation of this therapy for more than three years. Summary of clinical evidence: Citation Spreckley, 2009 Content, methods, recommendations Key points: Meta-analysis of 13 studies, six were randomized comparison trials. ABA programs did not significantly improve the cognitive outcomes of children in the experimental group who scored a standardized mean difference (SMD) of 0.38 (95%CI -0.09 to 0.84; P =.1). There was no additional benefit over standard care for expressive language; SMD of 0.37 (95%CI -0.09 to 0.84; P =.11). Results for receptive language: SMD of 0.29 (95%CI -0.17 to 0.74; P =.22) or adaptive behavior: SMD of 0.30 (95%CI -0.16 to 0.77; P =.20). Howlin, 2009 Key points: Systematic review of 11 studies, including two randomized controlled trials. At group level, EIBI resulted in improved outcomes (primarily measured by IQ) compared to comparison groups. At an individual level, however, there was considerable variability in outcomes, with some evidence that initial IQ (but not age) was related to progress. There is some evidence for the effectiveness of EIBI for some, but not all, preschool children with autism. Glossary Applied behavioral analysis (ABA) This behavioral treatment is the only treatment that has been determined to be efficacious in the treatment of some children diagnosed with ASDs according to the Chambliss Criteria used to evaluate the degree of published empirical support for psychosocial interventions. 8

Early intensive behavioral intervention (EIBI) A specific type of ABA for very young children with an ASD. The children are usually younger than five and often younger than three. Individuals with Disabilities Education Act (IDEA) Federal legislation providing students with disabilities access that is tailored to individual needs with a free appropriate public education (FAPE). Related policies AmeriHealth Caritas District of Columbia Utilization Management program description. References Professional society guidelines/other: Physician fact sheets, autism checklist for health care professionals. American Academy of Pediatrics. http://www.amchp.org/programsandtopics/cyshcn/projects/spharc/cdc%20act%20early %20Grants/Documents/Scan033.PDF. Accessed April 24, 2015 Autism spectrum disorders. American Psychiatric Association. http://www.psychiatry.org/autism. Accessed April 24, 2015. Dawson G, Burner K. Behavioral interventions in children and adolescents with autism spectrum disorder: a review of recent findings. Curr Opin Pediatr. December 2011; 23(6):616 20. Dorsey MF, Weinberg M, Zane T, Guidi MM. The case for licensure of applied behavior analysts. Behav Anal Pract. Spring 2009; 2(1):53 58. Volkmar F, Siegel M, Woodbury-Smith M, King B, McCracken J, State M. American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. February 2014; 53(2):237 57. Professional society guidelines as websites: National Autism Center The National Standards Project. Addressing the Need for Evidence-based Practice Guidelines for Autism Spectrum Disorders. http://www.nationalautismcenter.org/nationalstandards-project/. Accessed April 24, 2015. Centers for Disease Control and Prevention (CDC) Autism A.L.A.R.M. guidelines. http://www.medicalhomeinfo.org/downloads/pdfs/autismalarm.pdf. Accessed April 24, 2015. CDC. Autism Recommendation and Guidelines. http://www.cdc.gov/ncbddd/autism/hcp-recommendations.html. Accessed April 24, 2015. 9

CDC. Autism Treatment Recommendation. http://www.cdc.gov/ncbddd/autism/treatment.html. Accessed April 24, 2015. American Academy of Pediatrics. Policy Statements and Clinical Papers. http://aap.org/healthtopics/autism.cfm. Accessed April 24, 2015. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children, adolescents and adults with autism and other PDDs. http://www.jaacap.com/article/s0890-8567(13)00819-8/fulltext. Accessed April 24, 2015. American Academy of Neurology. Practice parameter: screening and diagnosis of autism. http://www.neurology.org/content/55/4/468.full.pdf. Accessed April 24, 2015. Peer-reviewed references: Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson J, Donaldson A, Varley J. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. January 2010; 125(1):e17 23. Howlin P, Magiati I, Charman T. Systematic review of early intensive behavioral interventions for children with autism. Am J Intellect Dev Disabil. January 2009; 114(1):23 41. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. October 17, 2012; 10:CD009260. Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. October 17, 2012; 10:CD009260. Spreckley M, Boyd R. Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language and adaptive behavior: a systematic review and meta-analysis. J Pediatr. March 2009; 154(3):338 44. Warren Z, McPheeters ML, Sathe N, Foss-Feig JH, Glasser A, Veenstra-Vanderweele J. A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics. May 2011; 127(5):e1303 11. Clinical trials: Social Motivation Intervention for Children with Autism Spectrum Disorder: Improving Peer Initiation NCT02360449. Stanford University. The purpose of this study is to investigate whether a social initiation motivation intervention (SIMI) focused on training children with ASD to initiate to peers during structured play activities 10

will result in more frequent initiations to typically developing peers during free play. The SIMI approach under investigation uses behavioral strategies based in applied behavior analysis and pivotal response treatment to motivate children with ASD to initiate to peers. Children with ASD will be randomly assigned to either the SIMI or a waiting list. Treatment will be provided for eight weeks in the context of a weekly social skills group. Using Web-based Technology to Expand and Enhance Applied Behavioral Analysis Programs for Children With Autism in Military Families. NCT01614275. University of Nebraska, State University of New York. The purpose of this study is to determine the extent to which technology may be used to provide (a) state-of-the-art assessment and intervention for children diagnosed with autism and (b) parent and tutor training for those who care for these children. (CMS) National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill in accordance with those manuals. CPT Code Description Comment 0359T 0360T 0361T 0362T 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-toface 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 Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, 11

0363T 0364T 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T 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 Adaptive behavior treatment by protocol, administered by technician, face-toface with one patient; first 30 minutes of technician time Adaptive behavior treatment by protocol, administered by technician, face-toface with one patient; each additional 30 minutes of technician time Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time 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 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) 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); first 60 minutes of technicians' time, face-to-face with patient 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 ICD-9 Code Description Comment 299.00 Autistic state, current or active state 299.01 Autistic state, residual state 299.10 Childhood disintegrative disorder, current or active 299.11 Childhood disintegrative disorder, residual state 299.80 Asperger s disorder, current or active state 099.81 Asperger s disorder, residual state 299.90 Pervasive developmental disorder NOS, current or active 299.91 Pervasive developmental disorder NOS, residual state 12

ICD-10 Code Description Comment F84.0 Autistic disorder F84.2 Rett s syndrome F84.3 Other childhood disintegrative disorder F84.5 Asperger s syndrome F84.8 Other pervasive developmental disorder F84.9 Atypical autism HCPCS Level II H0031 H0032 H0046 H2012 H2014 H2019 Description Mental health assessment by non-physician [when specified as functional assessment and treatment plan developed for Applied Behavior Analysis (ABA) services by a Qualified Autism Service Provider (licensed clinician or Board Certified Behavioral Analyst (BCBA)) Mental health service plan development by non-physician [when specified as supervision of a Qualified Autism Service Professional or Paraprofessional by a Qualified Autism Service Provider] Mental health services, not otherwise specified [when specified as direct ABA services by a Qualified Autism Service Professional] Behavioral health day treatment, per hour [when specified as direct ABA services by a Qualified Autism Service Provider] Skills training and development, per 15 minutes [when specified as skill development, social skills group activity] Therapeutic behavioral services, per 15 minutes [when specified as direct ABA services by a Qualified Autism Service Paraprofessional] Comment For the following codes, when specified as ABA therapy 13