Benefit Application
Plans may wish to review their contract language on Autism Spectrum Disorder services to ensure that the contract language is consistent with the Plan’s medical policy.

Description
Applied Behavioral Analysis (ABA) for Autism Spectrum Disorder (ASD)
ASD is a medical, neurobiological, and developmental disorder, characterized by persistent deficits in social communication and interactions along with restricted, repetitive patterns of behavior, interests, or activities. According to the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) 5th edition, autism spectrum disorder (ASD) includes disorders previously referred to as atypical autism, Asperger’s disorder, childhood autism, childhood disintegrative disorder, early infantile autism, high-functioning autism, and Pervasive Developmental Disorders (PDD) not otherwise specified. Treatment programs are primarily focused on behavioral interventions with goals of increasing functional abilities, fostering independence, and improving overall quality of life for the child and family. An example of one treatment approach for ASD is Applied Behavioral Analysis (ABA). ABA is an empirically supported behavioral and developmental intervention. It is typically delivered in community settings, such as clinics, schools, and homes.

ABA for ASD includes efforts to reduce challenging behaviors, and to replace these with positive behaviors by improving skills, based upon Skinnerian concepts of conditioned responses. Another focus would be the development of the ability to generalize concepts already learned to novel situations. Aside from concentration on the core symptoms, there is a focus on attention and initiation as well. ABA techniques include Discreet Trial Training, Incidental Teaching, Pivotal Response Training, and Verbal Behavioral Intervention. The PECS (Picture Exchange Communication System) is based upon ABA concepts and is used for improving communication deficits. All involve a structured environment, predictable routines, functional as opposed to standardized treatment, a transition plan and significant family involvement. At the initial evaluation, target symptoms are identified, with designated interventions. There is also a need to provide an assessment mechanism at specified intervals.

Policy Guidelines
ABA for the treatment of autism spectrum disorder is considered MEDICALLY NECESSARY when ALL of the following criteria are met:

• Individual has a confirmed diagnosis of autism spectrum disorder from a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism.
• Treatment is provided by an appropriately trained, certified and/or licensed health care professional;
• Services are rendered appropriately (i.e., type, frequency, extent, site and duration) and expected to result in meaningful and measurable improvements.
• Treatment targets the core deficits of autism spectrum disorder (ASD) as set forth by the DSM-5-TR; treatment goals and clinical documentation must be focused on active ASD core symptoms, substantial deficits that inhibit daily functioning, and clinically significant behaviors.
• Supporting clinical documentation provided including required testing and results, plan of care with specific goals, medical history (which may include records relating to the initial diagnosis of ASD, or any co-morbid medical conditions) and any prior history of behavioral therapy.
• The ABA services recommended do not duplicate services provided or available to the member by other medical or behavioral health professionals. Examples include but are not limited to behavioral health treatment such as individual, group, and family therapies; occupational, physical, and speech therapies.
• Services are not provided related to learning, curriculum planning, educational achievement, or participation in special education programs. Covered services must not duplicate interventions that directly support academic achievement goals included in the member’s educational setting or those goals encompassed in the member’s Individualized Education Program (IEP)/Individualized Service Plan (ISP).

Provider Guidelines to Initiate Care

All of the following must be met:

• Documentation of diagnosis of ASD diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism. DSM-5-TR criteria are met for autism including severity scale.
• Completed psychological testing results performed by a licensed clinical psychologist, licensed psycho-educational specialist, psychiatrist, pediatric neurologist or developmental pediatrician (Testing results that are completed by a school psychologist and are reviewed and verified by a clinical psychologist, developmental pediatrician, pediatric neurologist, board certified pediatrician, psychiatrist or medical doctor experienced in the diagnosis of ASD can satisfy this psychological testing requirement.)
  • Diagnostic evaluation/testing should include at least one autism-specific standardized or semi-structured assessment method such as the ADOS-2, ADI-R, DISCO, or CARS-2 or CARS-2-HF. The assessment used should be appropriate to the child’s age, developmental level, language level, evaluation modality, presenting concerns, and referral question. One additional evidence-based autism spectrum disorder assessment is also required such as: MIGDAS-2, SRS-2, SCQ, ASRS, GARS-3, or similar autism rating/screening measures. The assessment tools should be interpreted as part of a broader clinical evaluation 
• The recipient is medically stable, medical causes of behavioral changes have been ruled out, and 24-hour medical/nursing monitoring or procedures provided in a hospital level of care are not required.

• As determined by validated developmental assessment tools, the eligible recipient does not participate at an age-appropriate level in home, school or community activities because of the presence of behavioral excess and/or the absence of functional skills that interfere with participation in these activities, and the target behaviors or skill deficits identified for ABA meet one or more of the following:

a. The target behavior or skill is 1 standard deviation or more below the mean, or

b. Represents a skill(s) that is important for successful participation in routine home, community, and/or school environments, or

c. Represents a behavior that poses significant threat of harm to the recipient or others.

• BCBA/BCaBA assessment and program plan that must include the following elements:
  • An assessment of behavior and skills using validated tools has been completed by a BCBA-D, BCBA, BCaBA. The Behavior Identification Assessment (BIA) must include observation in the member’s natural environment and measurement of the member’s behavior in both structured and unstructured situations. This includes determinations of baseline levels of adaptive and maladaptive behaviors and completion of a functional behavior assessment (FBA), as appropriate. No more than 50% of the assessment units can be conducted via telehealth. The BCBA-D, BCBA, or BCaBA completing the assessment must be located in the same state as the member or in a contiguous county. Assessments must be completed by the same ABA provider who will be administering the ABA treatment.
  • The assessment should include tools that include but are not limited to: the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), Early Start Denver Model Curriculum Checklist (ESDM curriculum checklist), Assessment of Basic Language and Learning Skills-Revised (ABLLS-R), Assessment of Functional Living Skills (AFLS).  The assessments must have corresponding graphical display and summary of results.
  • Achievement timeframes and appropriate mastery criteria for skill acquisition, behavior reduction, and caregiver goals
  • Signature, title, and date by the multidisciplinary team members including the parent and/or caregiver.  The parents/caregivers commit to participate in the goals of the treatment plan.
  • The program plan has the following elements:

a. Behaviorally specific, quantifiable goals, that relate to developmental deficits or behaviors that are important for successful participation in everyday activities, such as home, school or the community or pose a significant risk of harm to the recipient or others.

b. Objective, observable and quantifiable metrics with appropriate measurable dimensions are utilized to measure change toward the specific goal behaviors.

c. Documentation that adjunctive treatments (e.g., psychotherapy, group social skills training, medication services, educational services) have been considered for inclusion in the treatment plan, with the rationale for exclusion.

d. Fading, generalization, and transition plans for each goal as well as for services overall.

• Submission of signed ABA Service Provider Request form that includes hours requested, location of services, and state licensure.
• Assessment and observation are dated within 45 days prior to service request.
• If request includes non-standard codes, additional documentation is required to support the request.
• If ABA services are planned for a school place of service, the BIA must include a school-based observation that highlights the medical necessity of services delivered in the school setting, as well as a detailed functional behavior assessment.

Provider Guidelines for Continued Care

All of the following must be met:

• The individual shows improvement from baseline in skill deficits and problematic behaviors targeted in the approved treatment plan using objective, observable, and quantifiable metrics.
• As determined by validated developmental assessment tools, the eligible recipient still does not participate at an age appropriate level in home, school or community activities because of the presence of behavioral excess and/or the absence of functional skills that interfere with participation in these activities, and the target behaviors or skill deficits identified with ABA meet one or more of the following: 
  • The target behavior or skill is 1 standard deviation or more below the mean, or
  • Represents a skill(s) that is important for successful participation in routine home, community, and/or school environments, or
  • Represents a behavior that poses significant threat of harm to the recipient or others.

• The individual’s caregivers demonstrate continued commitment to participation in the recipient’s treatment plan and demonstrate the ability to apply those skills in naturalized settings as documented in the clinical record.
• The gains made toward developmental norms and behavioral goals cannot be maintained if care is reduced.
• Behavioral concerns are not exacerbated by the treatment process.
• The recipient maintains the required cognitive capacity to benefit from the care provided and to retain and generalize treatment gains.
• Documentation of gains made toward behavioral goals should occur at six (6) month intervals. More frequent documentation may be appropriate as indicated by acute clinical situations where the safety or welfare of the member is of concern.
• Submission of a BCBA/BCaBA assessment and program plan that includes the following elements:
  • ABLLS, AFLS, EFL or VB-MAPP or age-appropriate assessment present with corresponding graphical display and summary of results
  • Assessment and observation are dated within 45 days prior to service request. Anticipated outcomes stated as measurable goals related to each specific problematic behavior or skill deficit (language, imitation, social skills, cooperation, etc.).
  • Achievement timeframes for skill acquisition, behavior reduction, and caregiver goals.
  • Amount and type of parent/caregiver participation
  • Date of every ninety-day review and annual re-development
  • Signature, title and date by the multidisciplinary team members including the parent and/or caregiver.
  • Progress statements for all continued/in progress goals (skill acquisition, behavior reduction and replacement behavior), including barriers to progress and modifications to increase progress
  • Behavior reduction graphs included, displaying 6 months of data for continued/in progress and mastered goals as well as original baseline data
  • Skills acquisition graphs included, displaying 6 months of data for all continued/in progress and mastered goals as well as original baseline data
  • Parent/caregiver training graphs included, displaying 6 months of data for all continued/in progress and mastered goals as well as original baseline data
  • Transition (fading) plan documented and individualized with measurable criteria
• If request includes non-standard codes, additional codes, or an increase in hours requested, documentation is required to support the request.
• If services are planned to continue for a school place of service, the BIA must include a school-based observation that highlights the medical necessity of services delivered in the school setting, as well as a detailed functional behavior assessment.

Criteria for Discharge from Care

One of the following must be met:

• Treatment is making the symptoms or negative behavior(s) persistently worse.
• No meaningful, measurable change has been documented in the individual’s functioning and/or behavior(s) for a period of at least six months of optimal treatment.
• The individual has achieved adequate stabilization of functions and/or the challenging behavior(s), and less-intensive modes of treatment are appropriate. 
• The individual’s parent(s) and/or caregiver(s) demonstrate adequate skill in administering a long-term home-based program.
• The individual’s parent(s) and/or caregiver(s) have refused treatment recommendations.
• The individual demonstrates an inability to maintain long-term gains from continued care.

• The intervention is considered respite, shadow or companion services.

The following services are considered NOT MEDICALLY NECESSARY/INVESTIGATIONAL because their clinical value has not been established for the treatment of ASD:

• Auditory Integration Therapy
• Facilitated Communication,
• Holding Therapy,
• Movement Therapies,
• Music Therapy,
• Animal assisted Therapy,
• Psychoanalysis,
• Son Rise Program,
• Scotopic Sensitivity Training,
• Sensory Integration Therapy,
• Neurotherapy (EEG biofeedback),
• Gluten and casein free diets, mega-vitamin therapy, chelation of heavy metals, anti-fungal drugs for presumed fungal infection and secretin administration.
• Educational-based services including but not limited to, TEAACH, Higashi Schools/Daily Life, Individual Support Program, LEAP, SPELL, Waldon, Hanen, Early Bird, Bright Start, Social Stories, Gentle Teaching.

The following are also considered NOT MEDICALLY NECESSARY:

• ABA services for non-autism spectrum disorder (non-ASD) diagnoses. 
• ABA services delivered by individuals without appropriate training or supervision and provided outside the scope of licensure or competency.
• ABA services delivered as educational, recreational, or custodial services without a clinical treatment plan.
• ABA services for symptoms and behaviors that are not part of the core symptoms of ASD (i.e., impulsivity due to ADHD, reading difficulties due to learning disability, excessive worry due to anxiety disorder).
• Planned ABA treatment interventions that involve aversive techniques or restraints.
• Services outside of the physical space of the home, clinic, office, or school. Certain community settings such as sporting events, camps, and other settings are also excluded. Any location not listed explicitly must be reviewed and approved.
• ABA services while the member is at another medical appointment to include another family member’s appointment.
• ABA services by a clinic or agency owned by any private entity related to the same private entity that conducted the member’s autism spectrum disorder evaluation and diagnosis.
• ABA services provided directly by the member’s responsible adult (e.g., biological, adoptive or foster parents, guardians, court-appointed managing conservators, other family members by birth or marriage).
• Any ABA service without routine delivery of 97156 during the authorization period.
• ABA services billed as 97153 without the delivery of 97155 and 97156.
• ABA services billed as 97155 without delivery of 97153
• Two ABA providers billing at the same time
• Non-ABA-services by ABA providers including but not limited to cognitive behavior therapy, Acceptance and Commitment Therapy, Prolonged Exposure, group psychotherapy, etc
• ABA services designed to deliver educational curriculum, or assist member with homework or other educational assignments
• Any childcare, personal care, respite, or other services provided as a substitute for the parents or other caregiver responsible for the member.
• BT/RBT/BCaBA training or supervision hours required for credentialing and/or BACB certification. Clinical supervision hours for the purpose of professional board requirements are not part of medically necessary treatment. ABA procedure codes are intended to facilitate billable treatment services to a patient, exclusively. This does not prevent providers from considering any overlapping, direct or indirect case supervision completed within the billable treatment service as a part of overall supervision hours required; however, 97155 is only for direct patient focused treatment services.

The following activities are considered NOT MEDICALLY NECESSARY in the school place of service location:

• ABA services without a current IEP, FBA and BIP under the IDEA designation of autism spectrum disorder, as completed the member’s local public education facility.
• ABA services for a member that are written in the IEP and required to be provided without charge by the local public education facility in accordance with the Individual with Disabilities Act or other applicable laws and regulations.
• ABA services that do not target a specific school-based goal and a specific behavior excess or deficit, as clearly indicated during prior authorization.
• Educational ABA services, such as services typically provided through a school curriculum.
• Educational/academic and vocational rehabilitation services.
• ABA services in the school setting designed to function as staff support, shadow, classroom aide, paraprofessional, or support person to the member.
• ABA services in the school setting may only be delivered by a RBT, BCaBA, BCBA, or BCBA-D.

The following activities are considered NOT MEDICALLY NECESSARY in the home place of service location:

• ABA services delivered in home settings when an adult caregiver is not physically present within the home.
• ABA services delivered in home settings with the intent to deliver or facilitate independent educational or home-school curriculum.
• ABA services in the home setting must be delivered by a RBT, BCaBA, BCBA, or BCBA-D, who is targeting a specific behavior excess or deficit and is for a limited duration.

Provider Qualifications and Training Requirements

• ABA must be delivered by qualified providers who possess appropriate education, training, and supervision consistent with the scope of practice defined by applicable state licensure laws and professional standards.
• All providers must:
  • Practice within the scope of their licensure and certification
  • Maintain competency through ongoing education, supervision, and adherence to evidence-based practices

Definitions:

Board Certified Behavior Analyst-Doctoral^® (BCBA-D^®) refers to the doctoral designation for a BCBA with a doctoral degree in behavioral analysis. BCBA-Ds supervise the work of BCaBAs and RBTs.   

Board Certified Behavior Analyst^® (BCBA^®) refers to the graduate level professional in behavioral analysis who has the BACB (Behavioral Analyst Certification Board) certification or equivalent and/or appropriate licensure and can practice independently. BCBAs supervise the work of BCaBAs and RBTs.

Board Certified Assistant Behavior Analyst^® (BCaBA^®) refers to an undergraduate-level professional (four- year college degree) in behavior analysis who practices under the supervision of a BCBA. BCBAs may delegate services to a BCaBA who has been credentialed and is receiving required supervision. BCaBAs can supervise the work of RBTs.

Registered Behavior Technician ^TM (RBT^TM) refers to a paraprofessional in behavioral analysis who practices under the close, ongoing supervision of a BCBA-D, BCBA or BCaBA.   The RBT is primarily responsible for the direct implementation of behavior-analytic services. The individual supervising the RBT is responsible for the work performed by the RBT. RBTs must be 18 years of age or older, possess a minimum of a high school diploma or national equivalent, complete 40 hours of training, pass the RBT Competency Assessment and the RBT exam.

Behavior Technician refers to the person who practices under the close, ongoing supervision of a BCBA-D, BCBA or BCaBA. The behavior technician (BT) is primarily responsible for the direct implementation of the behavior-analytic services. The individual supervising the BT is responsible for the work performed by the BT. The BT must be 18 years of age or older and possess a minimum of a high school diploma or national equivalent. The BT must also have documented training in first aid, CPR, confidentiality, accountability, and prevention of abuse and neglect, and at least 12 hours of training in the implementation of applied behavioral analysis, including at least three hours of ASD-specific training.

BTs will be granted a one-time, 90-day grace period, during which they can render direct services while working to acquire their RBT credential. The grace period begins from the date of the first ABA service rendered, irrespective of group employment. The 90-day grace period does not reset if the BT’s employment status changes, or if the BT does not obtain their RBT credential. Due to the complexity of service provision in home and school-based service locations, BTs are only authorized to provide services independently in practice-based service locations during the 90 day grace period and only when a BCaBA/BCBA/BCBA-D is physically on site and available to intervene and assist as needed.

Caregiver refers to the individual’s responsible adult (e.g., biological, adoptive or foster parents, guardians, court-appointed managing conservators, other family members by birth or marriage).

References

1. Aman, M.G. (2005). Treatment planning for patients with autism spectrum disorders. Journal of Clinical Psychiatry, 66 (Suppl. 10), 38-45.
2. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Revised 2014.  Available at: https://www.jaacap.org/article/S0890-8567(13)00819-8/pdf.
3. American Academy of Pediatrics Committee on Children With Disabilities. (2001). The pediatrician’s role in the diagnosis and management of autistic spectrum disorder in children. Pediatrics, 107 (5), 1221-1226.
4. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders-5. Washington, DC: Author.
5. Bailey, D. B., Hebbeler, K., Spiker, D., Scarborough, A., Mallik, S. & Nelson, L. (2005). Thirty-Six-Month Outcomes for Families of Children Who Have Disabilities and Participated in Early Intervention. Pediatrics, 116 (6), 1346-1352.
6. Baranek, G. T., David, F. J., Poe, M. D., Stone, W. L. & Watson, L. R. (2006). Sensory Experiences Questionnaire: discriminating sensory features in young children with autism, developmental delays, and typical development. Journal of Child Psychology and Psychiatry, 47 (6), 591-601.
7. Ben-Itzchack, E. & Zachor, D. A. (2007). The effects of intellectual functioning and autism severity on outcome of early behavioral intervention for children with autism. Research in Developmental Disabilities, 28 (3), 287-303.
8. Bodfish, J. (2004). Treating the core features of autism; are we there yet? Mental Retardation and Developmental Disabilities Research Reviews, 10 (4), 318-326.
9. Bryson, S. E., Zwaigenbaum, L., McDermott, C., Rombough, V. & Brian, J. (2008). The Autism Observation Scale for Infants: scale development and reliability data. Journal of Autism and Developmental Disorders, 38 (4), 731-738.
10. Capo, L. C. (2001). Autism, employment and the role of occupational therapy. Work, 16 (3), 201-207.
11. Cohen, H., Amerine-Dickens, M. & Smith, T. (2006). Early Intensive Behavioral Treatment: Replication of the UCLA Model in a Community Setting. Developmental and Behavioral Pediatrics, 27 (2), S145-155.
12. De Bildt, A., Sytema, S., Ketelaars, C., Kraijer, D., Mulder, E., Volkmar, F., and Minderaa, R. (2004). Interrelationship between Autism Diagnostic Observation Schedle-Generic (ADOS-G), Autism Diagnostic Interview-0Revised (ADI-R), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) Classification in Children and Adolescents with Mental Retardation. Journal of Autism and Developmental Disorders, 34 (2), 129-137. Available online at: http://www.aspires-relationships.com/Interrelationship_Between_Autism_Diagnostic_Observation_Schedule_Generic.pdf. Last viewed on October 25, 2013.
13. Eikeseth, S. (April 2008). Outcome of comprehensive psycho-educational interventions for young children with autism. Research in Developmental Disabilities; epublished April 1, 2008. Available online at:http://www.asatonline.org/resources/research/psychoeducational. Last viewed on October 25, 2013.
14. Eldevik, S., Eikeseth, S., Jahr, E. & Smith, T. (2006). Effects of Low-Intensity Behavioral Treatment for Children with Autism and Mental Retardation. Journal of Autism and Developmental Disorders, 36 (2), 211-224.
15. Eldevik, S., Hastings, R., Hughes, J., Jahr, E., Eikeseth, S. and Cross, S. (2009). Meta-Analysis of Early Intensive Behavioral Intervention for Children with Autism. Journal of Clinical Child and Adolescent Psychology, 38 (3), 439-450.
16. Eikeseth, S., Smith, T., Jahr, E. & Eldevik, S. (2002). Intensive Behavioral Treatment at School for 4- to 7-Year-Old Children with Autism: A 1-Year Comparison Controlled Study. Behavior Modification, 26 (1), 49-68.
17. Eikeseth, S., Smith, T., Jahr, E. & Eldevik, S. (2007). Outcome for Children With Autism Who Began Intensive Behavioral Treatment Between Ages 4 and 7: A Comparison Controlled Study. Behavior Modification, 31 (3), 264-278.
18. Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Dawson, G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. J., Levy, S. E., Minshew, N. J., Prizant, B. M., Rapin, I., Rogers, S. J., Stone, W. L., Teplin, S. W., Tuchman, R. F. & Volkmar, F. R. (1999). The screening and diagnosis of autism spectrum disorders.  Journal of Autism and Developmental Disorders, 29 (6), 439-484.
19. Filipek, P. A., Accardo, P. J., Ashwal, S., Baranek, G. T., Cook, Jr., E. H., Dawson, G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. J., Levy, S. E., Minshew, N. J., Ozonoff, S., Prizant, B. M., Rapin, I., Rogers, S. J., Stone, W. L., Teplin, S. W., Tuchman, R. F. & Volkmar, F. R. (2000). Practice parameter: Screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology, 55 (4), 468-479.
20. Filipek, P. A., Steinberg-Epstein, R. & Book, T. M. (2006). Intervention for Autistic Spectrum Disorders. NeuroRx^TM: The Journal of the American Society for Experimental NeuroTherapeutics, 3 (2), 207-216.
21. Findling, R. L. (2005). Pharmacologic treatment of behavioral syndromes in autism and pervasive developmental disorders. Journal of Clinical Psychiatry, 66 (Suppl. 10), 26-31.
22. Fombonne, E. (2005). Epidemiology of autistic disorder and other pervasive developmental disorders. Journal of Clinical Psychiatry, 66 (Suppl. 10), 3-8.
23. Francis, K. (2005). Autism interventions: a critical update. Developmental Medicine and Child Neurology, 47 (7), 493-499.
24. Geschwind, D. H. (2009). Advances in Autism. Annual Review of Medicine, 60, 367-380.
25. Glogowska, M., Roulstone, S., Peters, T. J., & Enderby, P. (2006). Early speech- and language-impaired children: linguistic, literacy, and social outcomes. Developmental Medicine & Child Neurology, 48 (06), 489-494.
26. Gotham, K., Risi, S., Pickles, A. & Lord, C. (2007). The Autism Diagnostic Observation Schedule: revised algorithms for improved diagnostic validity. Journal of Autism and Developmental Disorders, 37 (4), 613-627.
27. Gurney, J. G., McPheters, M. L., & Davis, M. M. (2006). Parental report of health conditions and health care use among children with and without autism: National Survey of Children’s Health. Archives of Pediatrics and Adolescent Medicine, 160 (8), 825-830.
28. Harris, S. (2003). Functional assessment. Journal of Autism and Developmental Disorders, 33 (2), 233.
29. Hastings, R. (2003). Behavioral adjustment of siblings of children with autism engaged in applied behavior analysis early intervention programs: The moderating role of social support. Journal of Autism and Developmental Disorders, 33 (2), 141-150.
30. Hoehn, T. P. & Baumeister, A.  A. (1994). A Critique of the Application of Sensory Integration Therapy to Children with Learning Disabilities. Journal of Learning Disabilities, 27 (6), 338-350.
31. Howes, O. D., Rogdaki, M., Findon, J. L., WIchers, R. H., Charman, T., King, B. H., Loth, E., McAlonan, G. M., McCracken, J. T., Parr, J. R., Povey, C., Santosh, P., Wallace, S., Simonoff, E., & Murphy, D. G. (2018). Autism spectrum disorder: Consensus guidelines on assessment, treatment and research from the British Associate for Psychopharmacology. Journal of Psychopharmacology, 33 (1), 3-29.
32. Howlin, P. (2005). The effectiveness of interventions for children with autism. Journal of Neural Transmission, Suppl. (69), 101-119.
33. Howlin, P., Magiati, I. & Charman, T. (2009). Systematic Review of Early Intensive Behavioral Interventions for Children with Autism. American Journal on Intellectual and Developmental Disabilities, 114 (1), 23-41.
34. Hyman, S. L. & Levy, S. E. (2005). Introduction: Novel Therapies in Developmental Disabilities – Hope, Reason, and Evidence. Mental Retardation and Developmental Disabilities, 11 (2), 107-109.
35. Hyman, S. L., Levy, S. E., & Myers, S. M. (2020). Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics, 145 (1). Available online at: Identification, Evaluation, and Management of Children With Autism Spectrum Disorder | Pediatrics | American Academy of Pediatrics (aap.org).
36. Iarocci, G. & McDonald, J. (2006). Sensory Integration and the Perceptual Experience of Persons with Autism. Journal of Autism and Developmental Disorders, 36 (1), 77-90.
37. Itzchak, E. B., Lahat, E., Burgin, R. & Zachor, A. D. (2008). Cognitive, behavior and intervention outcome in young children with autism. Research in Developmental Disabilities, 29 (5), 447-458.
38. Johnson-Ecker, C. L. & Parham, L. D. (2000). The evaluation of sensory processing: A validity study using contrasting groups. American Journal of Occupational Therapy, 54 (5), 494-503.
39. Kasari, C., Freeman, S. & Paparell, T. (2006). Joint attention and symbolic play in young children with autism: a randomized controlled intervention study. Journal of Child Psychology and Psychiatry, 47 (6), 611-620.
40. Keen, D., Sigafoos, J., & Woodyatt, G. (2001). Replacing prelinguistic behaviors with functional communication. Journal of Autism and Developmental Disorders, 31 (4), 385-398.
41. Kleinman, J. M., Ventola, P. E., Pandey, J., Verbalis, A. D., Barton, M., Hodgson, S., Green, J., Dumont-Mathieu, T., Robins, D. L. & Fein, D (2008). Diagnostic stability in very young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 38 (4), 606-615.
42. Koegel, L. K. (2000). Interventions to facilitate communication in autism. Journal of Autism and Developmental Disorders, 30 (5), 383-391.
43. Legoff, D. & Sherman, M. (2006). Long-term outcome of social skills intervention based on interactive LEGO© play. Autism, 10 (4), 317-329.
44. Linderman, T. M. & Stewart, K. B. (1999). Sensory integrative-based occupational therapy and functional outcomes in young children with pervasive developmental disorders: A single-subject study. American Journal of Occupational Therapy, 53 (2), 207-213.
45. Lord, C. (2000). Commentary; achievements and future directions for intervention research in communication and autism spectrum disorders. Journal of Autism and Developmental Disorders, 30 (5), 393-398.
46. Mailloux, Z. (1990). An Overview of the Sensory Integration and Praxis Tests. American Journal of Occupational Therapy, 44 (7), 589-594.
47. Magiati, I., Charman, T. & Howlin, P. (2007). A two-year prospective follow-up study of community-based early intensive behavioural intervention and specialist nursery provision for children with autism spectrum disorders. Journal of Child Psychology and Psychiatry, 48 (8), 803-812.
48. Manning-Courtney, P., Brown, J., Molloy, C. A., Reinhold, J., Murray, D., Sorensen-Burnworth, R., Messerschmidt, T., & Kent, B. (2003). Diagnosis and treatment of autism spectrum disorders. Current Problems in Pediatric and Adolescent Health Care, 33 (9), 283-304.
49. Masi, G., Cosenza, A., Mucci, M., & Broredani, P. (2003). A 3-year naturalistic study of 53 preschool children with PDD treated with Risperidone. Journal of Clinical Psychiatry, 64 (9), 1039-1046.
50. McCarthy, H. (2006). Survey of Children Adopted from Eastern Europe – The Need for Special School Services. Available online at: http://www.postadoptinfo.org/research/survey_results.php. Last viewed on October 25, 2013.
51. McConnell, S. (2002). Interventions to Facilitate Social Interaction for Young Children with Autism: Review of Available Research and Recommendations for Educational Intervention and Future Research. Journal of Autism and Developmental Disorders, 32 (5), 351-372.
52. McDougle, C. J., Erickson, C. A., Stigler, K. A., & Posey, D. J. (2005). Neurochemistry in the pathophysiology of autism. Journal of Clinical Psychiatry, 66 (Suppl. 10), 9-18.
53. Mostert, M. P. (2001). Facilitated communication since 1995; a review of published studies. Journal of Autism and Developmental Disorders, 31 (3), 287-313.
54. Myers, S. M. & Plauche’ Johnson, C. (2007). Management of Children with Autism Spectrum Disorders. Pediatrics, 120 (5), 1162-1182.
55. Oneal, B. J., Reeb, R. N., Korte, J. R. & Butter, E. J. (2006). Assessment of Home-Based Behavior Modification Programs for Autistic Children: Reliability and Validity of the Behavioral Summarized Evaluation. Journal of Prevention & Intervention in the Community, 32 (1-2), 25-39.
56. Ospina, M. B., Krebs Seida, J., Clark B., Karkhaneh, M., Hartling, L., Tjosvold, L., Vandermeer, B. & Smith, V. (2008). Behavioural and Developmental Interventions for Autism Spectrum Disorder: A Clinical Systematic Review. PLoS ONE, 3 (11), e3775.
57. Ottenbacher, K. (1982). Sensory Integration Therapy: Affect or Effect. American Journal of Occupational Therapy, 36 (9), 571-578.
58. Posey, D. J. & McDougle, C. J. (2002). Autism: A three-step practical approach to making the diagnosis. Current Psychiatry, 1 (7), 20-28.
59. Reichow, B. & Wolery, M. (2008). Comprehensive Synthesis of Early Intensive Behavioral Interventions for Young Children with Autism Based on the UCLA Young Autism Project Model. Journal of Autism and Developmental Disorders, 39 (1), 23-41.
60. Remington, B., Hastings, R. P., Kovshoff, H., degli Espinosa, F., Jahr, E., Brown, T., ALsford, P., Lemaic, M. & Ward, N. (2007). Early Intensive Behavioral Intervention: Outcomes for Children With Autism and Their Parents After Two Years. American Journal on Mental Retardation, 112 (6), 418-438.
61. Rogers, S. and Vismara, L. (2008). Evidence-based Comprehensive Treatments for Early Autism. Journal of Clinical Child and Adolescent Psychology, 37 (1), 8-38.
62. Rogers, S. J. & Ozonoff, S. (2005). Annotation: What do we know about sensory dysfunction in autism? A critical review of the empirical evidence. Journal of Child Psychology and Psychiatry, 46 (12), 1255-1268.
63. Roley, S., Clark, G., Bissell, J. & Brayman, S. (2003). Applying Sensory Integration Framework in Educationally Related Occupational Therapy Practice (2003 Statement). American Journal of Occupational Therapy, 57 (6), 652-659.
64. Sacco, R., Militerni, R., Frolli, A., Bravaccio, C., Griti, A., Elia, M., Curatolo, P., Manzi, B., Trillo, S., Lenti, C., Saccani, M., Schneider, C., Melmed, R., Reichelt, K. L., Pascucci, T., Puglisi-Allegra, S. & Persico, A. M. (2007). Clinical, morphological, and biochemical correlates of head circumference in autism. Biological Psychiatry, 62 (9), 1038-1047.
65. Sallows, G. O. & Graupner, T. D. (2005). Intensive Behavioral Treatment for Children With Autism: Four-Year Outcome and Predictors. American Journal on Mental Retardation, 110 (6), 417-438.
66. Sandler, A. (2005). Placebo Effects in Developmental Disabilities: Implications for Research and Practice. Mental Retardation and Developmental Disabilities, 11 (2), 164-170.
67. Scanhill, L. (2005). Diagnosis and evaluation of pervasive developmental disorders. Journal of Clinical Psychiatry, 66 (Suppl. 10), 19-25.
68. Schaaf, R. C. & Miller, L. J. (2005). Occupational Therapy Using a Sensory Integrative Approach for Children with Developmental Disabilities. Mental Retardation and Developmental Disabilities, 11 (2), 143-148.
69. Schaaf, R. C. & Nightlinger, K. M. (2007). Occupational therapy using a sensory integrative approach: A case study of effectiveness. American Journal of Occupational Therapy, 61 (2), 239-246.
70. Science 2.0. How Well Do Adopted Children Really Adjust To A New Language? Available at: http://www.science20.com/news_releases/how_well_do_adopted_children_really_adjust_new_language. Last viewed on October 25, 2013.
71. Shevell, M., Ashwal, S., Donley, D., Flint, J., Gingold, M., Hirtz, D., Majnemer, A., Noetzel, M. & Sheth, R. (2003). Practice parameter: Evaluation of the child with global developmental delay: Report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology, 60 (3), 367-380.
72. Shook, G. L., Ala’i-Rosales, S. & Glenn, S. (2002). Training and Certifying Behavior Analysts. Behavior Modification, 26 (1), 27-48.
73. Sikora, D. M., Hall, T. A., Hartley, S. L., Gerrard-Morris, A. E. & Cagle, S. (2008). Does Parent Report of Behavior Differ Across ADOS-G Classifications: Analysis of Scores from the CBCL and GARS. Journal of Autism and Developmental Disorders, 38 (3), 440-448.
74. Smith, S., A., Press, B., Koenig, K. P., & Kinnealey, M. (2005). Effects of sensory integration intervention on self-stimulating and self-injurious behaviors. American Journal of Occupational Therapy, 59, 418-425.
75. Stahmer, A., Ingersoll, B., & Carter, C. (2003). Behavioral approaches to promoting play. Autism, 7 (4), 401-413.
76. South Carolina Department of Health and Human Services (SCDHHS). (2006).  Application for 1915 HCBS Waiver. Available online at: https://www.scdhhs.gov/sites/default/files/PDD%20Waiver%20Application.pdf. Last viewed on October 25, 2013.
77. The University of Stavanger (2008, December 19). Up To A Third of Children Adopted To Norway From Abroad Are Having Problems With Language Proficiency. ScienceDaily. Available at: http://www.sciencedaily.com/releases/2008/12/081219073053.htm. Last viewed on October 25, 2013.
78. U.S. Department of Defense. (2007). Department of Defense Report and Plan on Services to Military Dependent Children with Autism. Available online at: http://www.bacb.com/Downloadfiles/707_DoD_TRICARE_rpt.pdf. Last viewed on October 25, 2013.
79. Vargas, S. & Camilli, G. (1999). A meta-analysis of research on sensory integration treatment. American Journal of Occupational Therapy, 53 (2), 189-198.
80. Volkmar, F., Paul, R., Klin, A. & Cohen, D. (2005). Handbook of Autism and Pervasive Developmental Disorders (Vol. 1, 3^rd ed., text rev.). Hoboken, NJ: John Wiley & Sons, Inc.
81. Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J. H., Jerome, R. N., Krishnaswami, S., Sathe, N. A., Glasser, A. M., Surawicz, T., McPheeters, M. L. (2011). Therapies for Children With Autism Spectrum Disorders. Comparative Effectiveness Review No. 26. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I.) AHRQ Publication No. 11-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2011. Available online at: http://www.effectivehealthcare.ahrq.gov/ehc/products/106/656/CER26_Autism_Report_04-14-2011.pdf. Last viewed on October 25, 2013.
82. Watling., R. L., Deitz, J. & White. O. (2001). Comparison of Sensory Profile scores of young children with and without autism spectrum disorders. American Journal of Occupational Therapy, 55 (4), 416-423.
83. Watling, R., Tomchek, S., & LaVesser, P. (2005). The scope of occupational therapy services for individuals with autism spectrum disorders across the lifespan. The American Journal of Occupational Therapy, 59 (6), 680-683.
84. Werner DeGrace, B. (2004). The everyday occupation of families with children with autism. American Journal of Occupational Therapy, 58, 543-550.
85. Whalen, C. & Schreibman, L. (2003). Joint attention training for children with autism using behavior modification procedures. Journal of Child Psychology and Psychiatry, 44 (3), 456-468.
86. Windsor, J., Doyle, S. S., & Siegel, G. M. (1994). Language acquisition after mutism; a longitudinal case study of Autism. Journal of Speech and Hearing Research, 37 (1), 96-105.
87. Yoder, P. & McDuffie, A. (2006). Teaching young children with autism to talk. Seminars in Speech and Language, 27 (3), 161-172.
88. Yoder, P. & Stone, W. L. (2006). Randomized comparison of two communication interventions for preschoolers with autism spectrum disorders. Journal of Consulting and Clinical Psychology, 74 (3), 426-435.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes.

Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines.

They are listed in the Category Search on the Medical Policy search page.

Applicable service codes:

0362T Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to face with a patient, requiring the following components:

· administered by the physician or other qualified health care professional who is on site,

· with the assistance of two or more technicians,

· for a patient who exhibits destructive behavior,

· completed in an environment that is customized to the patient’s behavior.

0373T Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components:

· administered by the physician or other qualified health care professional who is on site,

· with the assistance of two or more technicians,

· for a patient who exhibits destructive behavior,

· completed in an environment that is customized to the patient’s behavior.

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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