Clinical UM Guideline

IMPORTANT INFORMATION ABOUT THIS GUIDELINE:

This guideline is to be applied to the extent there is a state mandate or specific benefit coverage for an Adaptive Behavioral Treatment (ABT) such as Intensive Behavioral Intervention (IBI) or Applied Behavioral Analysis (ABA).

This document addresses the treatment of ASDs and other Pervasive Developmental Disorders (PDDs) with behavioral interventions such as ABA when a state requires or benefit language explicitly provides coverage for the behavioral intervention(s). In this document, the term ‘ABT’, which includes services such as ABA and IBI, refers to services that may be provided as part of ABA and IBI.

ABT is used for treatment of Autism Spectrum Disorder (ASD). The diagnosis of ASD can be complex and difficult due to the diversity of the presentation of symptoms and their severity. Due to the multitude of possible causes and potential confusion with other conditions, many tests exist to diagnose ASD that may or may not be appropriate. It is vital that parents or guardians of children suspected of having an ASD seek early diagnosis and care for the child to increase any potential benefits of treatment. The recommendations for evaluation and assessment of ASD as published by the American Academy of Pediatrics (Zwaigenbaum, 2015b), and the American Academy of Child and Adolescent Psychiatry (Volkmar, 2014) are resources that can be utilized.

ASD, as defined in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes disorders previously referred to as:

• Atypical autism
• Asperger’s disorder
• Childhood autism
• Childhood disintegrative disorder
• Early infantile autism
• High-functioning autism
• Kanner’s autism
• PDD not otherwise specified

Note: Benefits, state mandates and regulatory requirements should be verified prior to application of criteria listed below.

Note: For information regarding testing or treatment of ASD and other related conditions, please see:

• CG-BEH-15 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

I.  Assessment and Planning

The assessment and planning for an initial course of behavioral intervention services may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria are met:

1. A diagnosis of ASD has been made by a licensed medical professional or other qualified health care professional as is consistent with state licensing requirements; and
2. Documentation is provided which describes the person-centered treatment plan that includes all of the following:
   1. Addresses the identified behavioral, psychological, family, and medical concerns; and
   2. Has measurable goals in objective and measurable terms based on standardized assessments that address the behaviors and impairments for which the intervention is to be applied (Note: this should include, for each goal, baseline measurements, progress to date and anticipated timeline for achievement based on both the initial assessment and subsequent interim assessments over the duration of the intervention); and
   3. Documents that ABT services will be delivered by an appropriate provider who is licensed or certified according to applicable state laws and benefit plan requirements; and
3. Assessments of motor, language, social, and adaptive functions have been completed; and
4. The person-centered ABT treatment plan incorporates goals appropriate for the individual’s age and impairments including social, communication, language skills or adaptive functioning that have been identified as deficient relative to age expected norms with these elements for each target:
   1. Anticipated timeline for achievement of the goal(s), based on both the initial assessment and subsequent interim assessments over the duration of the intervention; and
   2. Family education and training interventions including the behavior parents/caregivers are expected to demonstrate; and
   3. Estimated date of mastery; and
   4. Plan for generalization; and
   5. Discharge or transition planning.

One or more of the following ABT behavioral assessments may be covered when any of the criteria above have been met and the specific criteria for each type of assessment below have been met:

1. Behavior identification assessment: Required prior to beginning a course of ABT. Each request for ABT must include an assessment involving the use of a standardized assessment (for example, Verbal Behavior Milestones Assessment and Placement Program [VB-MAPP], the Vineland Adaptive Behavior Scale [Vineland], the Autism Diagnostic Observation Schedule [ADOS], etc.).
2. Behavior identification supporting assessment
   1. By one technician under the direction of a physician or other qualified health care professional:  May be necessary when one or more non-redirectable disruptive behaviors are present. A request for a behavior identification supporting assessment must provide a description of the disruptive behavior(s) identified. Examples of such behaviors are repetitive gestures or vocalizations, pica, elopement, etc. that are not manageable through redirection techniques.
   2. By a physician or other qualified health care professional present on site and with the assistance of two or more technicians:  May be necessary when one or more non-redirectable disruptive behaviors that pose significant risk of harm to the individual or others are present, and an appropriate intervention has been chosen and planned. The request must include the following: 
      1. Description of the behavior(s) that pose significant risk of harm to the individual or others; and
      2. Description of the plan to expose the affected individual to social or environmental stimuli associated with the disruptive behavior; and
      3. Description of how the assessment will be conducted in a setting conducive to the safety of the individual and other individuals who may be present, including but not limited to, physician, other qualified health care professional, or technician. Examples of such behaviors include repetitive biting, hitting or punching of self or others that are not manageable through redirection techniques.

Notes:
The conduction of the behavior identification assessment and behavior identification supporting assessment together should comprise up to 20 hours of evaluation time. If more than 20 hours of behavior identification assessment and behavior identification supporting assessment together are requested, a rationale must be provided with the request describing the specific situation that warrants additional assessment time.

Repeat behavior identification assessment and behavior identification supporting assessment may be needed when indicated by periodic measurements using standardized assessments. Such repeat assessment should be comprised of fewer than 20 hours in a 6 month interval. More than 20 hours should result in an updated treatment and progress report.

II.  Adaptive Behavioral Treatment (ABT)

Adaptive behavior treatment by protocol may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria have been met:

1. The individual has met the criteria above for initial or continuing treatment; and
2. The treatment plan should include treatment with a certified or licensed physician, qualified healthcare provider, or ABT technician (in accordance with state law and benefit plan requirements) for 40 hours per week or less; and
   Note: ABT services for more than 40 hours per week have not been shown to be more effective and documentation as to why more than 40 hours per week is planned must be provided.
3. A certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements) provides protocol modification; and
4. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours requested for each behavioral target. The total hours of ABT requested should be comprised of 40 hours per week or less.

Adaptive behavior treatment with protocol modification:

Protocol modification of ABT treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria are met:

1. The individual has met the criteria above for an initial course of ABT; and
2. The individual has met the criteria below for ABT with protocol modification; and
3. The professional is an appropriate provider who is licensed or certified according to the requirements of applicable state laws and benefit plan requirements to perform the protocol modification of services; and
4. Up to two (2) hours of protocol modification will be covered for every ten (10) hours of direct ABT therapy. Any greater frequency of protocol modification will require written documentation demonstrating the need for additional protocol modification.

Criteria for adaptive behavior treatment with protocol modification:

1. By a physician or other qualified health care professional present on site which may include simultaneous direction of a technician may be covered when all of the following criteria have been met:
   1. The person-centered treatment plan details the treatment goals for the treatment, describing the type, severity, and frequency of the specific non-redirectable disruptive behaviors; and
   2. The intervention request should specify the services and key functional skills to be included for the target(s); and
   3. The treatment is administered by a certified or licensed physician, qualified healthcare provider, with no more than one technician present; and
   4. The hours of treatment requested should be included in the total hours of ABT requested.
2. By a physician or other qualified health professional present on site and with the assistance of two or more technicians: May be covered when one or more non-redirectable destructive behaviors that pose significant risk of harm to the individual or others are present, and an appropriate intervention has been chosen and planned. The request must include the following: 
   1. Description of the behavior(s) that pose significant risk of harm to the individual or others; and
   2. Description of how the plan is to expose the individual to social or environmental stimuli associated with the destructive behavior; and
   3. Description of how the assessment will be conducted in a setting conducive to the safety of the individual and other individuals who may be present, including but not limited to, physician, other qualified health care professional, or technician.

Note: The total hours of adaptive behavior treatment with protocol modification requested should be comprised of 8 hours or less per week. If additional treatment time is requested a rationale must be provided with the request describing the specific situation that warrants additional time.

Group adaptive behavior treatment by protocol may be covered when all of the following criteria have been met:

1. The person-centered treatment plan addresses specific treatment goals and targeted problem areas; and
2. The goal is to train a group of individuals in the use of behavioral techniques to reduce maladaptive behaviors and increase skill acquisition; and
3. The session is conducted by a certified or licensed physician, qualified healthcare provider, or ABT technician (in accordance with state law and benefit plan requirements); and
4. The individual has sufficient social, language, and adaptive skills to participate in group adaptive behavior treatment; and
5. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours requested for each behavioral target. The total hours of group adaptive behavior treatment requested should be included in the 40 hours per week.

Group adaptive behavior treatment with protocol modification may be covered when all of the following criteria have been met:

1. The person-centered treatment plan addresses specific treatment goals and targeted problem areas; and
2. The goal is to train a group of individuals in the use of social skills to reduce maladaptive behaviors and increase social interactions; and
3. The session is conducted by a certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements); and
4. The individual has sufficient social, language, and adaptive skills for the individual to participate in group adaptive behavior treatment; and
5. The hours of services should reflect the number of behavioral targets, services, and key functional skills to be addressed, with a clinical summary justifying the hours of social skills group. The total hours of group adaptive behavior treatment requested should be included in the 40 hours per week.

Family adaptive behavior treatment guidance may be covered when all of the following criteria have been met:

1. The goal of the guidance is to provide instruction to a parent, guardian, or other caregiver the treatment protocols to use in reducing the affected individual’s maladaptive behaviors and increase generalization of skills; and
2. The person-centered treatment plan addresses targeted behaviors and specific goals based on assessment of the affected individual; and
3. The scope of the intervention for the targeted behaviors is within the context of management by the family and is such that the guidance may be performed with or without the affected individual present.

Multiple-family group adaptive behavior treatment guidance may be covered when all the following criteria have been met:

1. The person-centered treatment plan addresses specific treatment goals and targeted problem areas; and
2. The goal is to train a group of parents, guardians, or caregivers in the use of behavioral techniques to reduce maladaptive behaviors and skill deficits; and
3. The session is conducted by a certified or licensed physician, qualified healthcare provider (in accordance with state law and benefit plan requirements); and
4. The intervention is based upon the affected individuals sharing at least one common behavioral target and possible key functional skills that will benefit the individual by group intervention as explained in the clinical summary; and
5. The scope of the intervention for the targeted behaviors is within the context of management by the families and is such that the guidance must be performed in the absence of the affected individual.

III.  Continuation of treatment

Continuation of ABT treatment may be covered for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABT and ALL of the following selection criteria are met:

1. The individual continues to meet the criteria above for an initial course of ABT; and
2. The person-centered treatment plan will be updated and submitted, in general, every 6 months or as required by a state mandate. Note: Treatment plans may be required more often than every 6 months, for example, when behavior identification supporting assessment or behavioral ABT with protocol modification are required; and
3. The person-centered treatment plan includes age and impairment appropriate goals and measures of progress. The treatment plan should include measures of the progress made with social skills, communication skills, language skills, adaptive functioning, and specific behaviors or deficits targeted. Clinically significant progress in social skills, communication skills, language skills, and adaptive functioning must be documented as follows:
   1. Interim progress assessment at least every 6 months based on clinical progress toward treatment plan goals; and
   2. Developmental status as measured by standardized assessments no less frequent than every 2 years*; and
4. For each goal in the person-centered treatment plan, the following is documented:
   1. Progress-to-date relative to baseline measures is described; and
   2. Anticipated timeline for achievement of the goal(s), based on both the initial assessment and subsequent interim assessments over the duration of the intervention; and
   3. Family education and training interventions including the behavior parents/caregivers are expected to demonstrate and utilize outside the treatment setting (for example, at home or in the community); and
   4. Estimated date of mastery; and
   5. Plan for generalization; and
   6. Transition/fade and discharge planning.

Note: The number of hours allotted for direct treatment with the individual can continue to be up to 40 hours a week. The hours should be reviewed regularly, and adjusted to address the behavioral targets and key functional skills of the individual, based on the results of the assessments mentioned above.

*Systematic and repeated evaluation of developmental status is critical to assessing the effect of therapeutic treatments, including ABT. The use of standardized assessments facilitates the consistent, systematic, and reliable evaluation early in the course of treatment, preferably before initiating ABT, and at regularly scheduled intervals thereafter. The data derived from these assessments is used to inform about the impact of treatment on the trajectory of the individual’s condition, especially documenting improvement. Examples of widely accepted and used standardized assessments include the VB-MAPP and the Vineland.

IV.  When Above Criteria Are Not Met

To the extent there is a state mandate or specific benefit coverage for ABT for an individual that allows ABT treatment to be reviewed using clinical criteria, ABT will be considered not covered and not medically necessary when either:

1. The criteria above are not met; or
2. There is no documentation of clinically significant progress in any of the following areas as measured by an interim progress evaluation through standardized assessments:
   1. Adaptive functioning; or
   2. Communication skills; or
   3. Language skills; or  
   4. Social skills.

ABT is considered not medically necessary for all indications other than ASD.

V.  Other Information:

Cognitive, developmental or intelligence quotient (IQ) testing is not required for an initial or continued course of ABT treatment to be covered.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be covered when criteria are met:
Note: The following list of procedure codes are examples only and may not represent all codes being used for ABT. Please contact the member’s plan for applicable coding conventions as these may vary.

When services may be not covered and not medically necessary:
Services may be considered not covered and not medically necessary when the criteria are not met or for situation described in the Clinical Indications section. 

When services are not medically necessary:
For ABT services for all other diagnoses not listed above.

The DSM-5-TR (2022) describes the essential diagnostic features of ASD as both a persistent impairment in reciprocal social communication and restricted and repetitive pattern of behavior, interest or activities. These attributes are present from early childhood and limit or impair everyday functioning. Parents may note symptoms as early as infancy, and the typical age of onset is before 3 years of age. Symptoms may include problems with using and understanding language; difficulty relating to or reciprocating with people, objects, and events; lack of mutual gaze or inability to attend events conjointly; unusual play with toys and other objects; difficulty with changes in routine or familiar surroundings, and repetitive body movements or behavior patterns. There are some exceptions to this, where in some circumstances a child may exhibit normal development for approximately 2 years followed by a marked regression in multiple areas of function.

Children with ASD vary widely in abilities, intelligence, and behaviors. Some children do not speak at all, others speak in limited phrases or conversations, and some have relatively normal language development. Repetitive play skills, resistance to change in routine and inability to share experiences with others, and limited social and motor skills are generally evident. Unusual responses to sensory information, such as loud noises and lights, are also common. Affected children can exhibit unusual behaviors occasionally or seem shy around others sometimes without having ASD. What sets children with ASD apart is the consistency of their unusual behaviors. Symptoms of the disorder have to be present in all settings, not just at home or at school, and over considerable periods of time. With ASD, there is a lack of social interaction, impairment in nonverbal behaviors, and a failure to develop normal peer relations. A child with an ASD tends to ignore facial expressions and may not look at others; other children may fail to respect interpersonal boundaries and come too close and stare fixedly at another person.

ASDs, under the DSM-5-TR paradigm, are classified by Severity Level (see Table 2 below). Level 1, “Requiring support,” is considered the least severe classification and includes individuals with mild deficits in social communications (as seen in individuals formerly diagnosed with Asperger’s syndrome). Level 3, “Requiring very substantial support,” is considered the most severe classification and includes individuals with no or extremely limited communication abilities.

The exact causes of autism are unknown, although genetic factors are strongly implicated. A clinical report published by the American Academy of Pediatrics (AAP) (2020) indicated that the prevalence of ASD in the United States is 1 in 59 children.

The specific DSM-5-TR diagnostic criteria for ASD are provided below:

DSM-5-TR Criteria for Autism Spectrum Disorder

Diagnostic criteria

1. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history (examples are illustrative, not exhaustive; see text);
   1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
   2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communications.
   3. Deficits in developing, maintaining and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social context; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
2. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text);
   1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
   2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
   3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
   4. Hyper- or hypoactivity to sensory inputs or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching or objects, visual fascination with lights or movement).
3. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learning strategies in later life).
4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2):
Requiring very substantial support
Requiring substantial support
Requiring support
Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Specify if:
Associated with a known genetic or other medical condition or environmental factor. (Coding note: Use additional code to identify the associated genetic or other medical condition)
Associated with a neurodevelopmental, mental, or behavioral disorder.
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder, p. 135 for definition). (Coding note: Use additional code F06.1 catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia).

* From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision. DSM-5-TR. American Psychiatric Association. Washington, DC.  February 2022. Page 58.

The treatment of ASD may take many different approaches, focusing on one or more aspects of the condition being treated. There is no single treatment that has consistently demonstrated benefit at the core symptoms of these disorders. Family therapy is generally supported as a valuable treatment because it offers emotional support and guidance to parents who will contend with a myriad of services to assist their child. Individual therapy using social story technique and behavioral cue coaching are very useful for the older child/adolescent with Asperger’s syndrome and can make a difference in that child’s acceptance by others. Educational therapy includes intensive one-on-one therapy involving a wide array of techniques focusing on improvement in social, communication, and language skills, and may include ABT.

ABT should be part of person-centered treatment plan that addresses the whole person. The plan is developed based on assessments of the individual’s behavioral, psychological, family, and medical health. The use of ABT begins with a thorough assessment of the individual for whom the treatment is requested. This assessment should include confirmation of a diagnosis of ASD made by a licensed medical professional, licensed psychologist, or other qualified health care professional. The evaluation of motor, language, social, adaptive, and/or cognitive functions is important to understand the individual’s baseline status and potential for improvement (Maglione, 2012). State mandates may limit the assessments that a health plan may require.

Visual Communication Analysis (VCA), which can be considered an extension or augmentation of ABA, is a personalized treatment for individuals with ASD. VCA is based on a theory of motivation known as Self-Determination Theory (SDT). Rather than using external rewards or punishments to shape children’s behavior, VCA seeks to create conditions under which children can develop their intrinsic motivation. VCA utilizes visual supports, prompting and technology such as tablets with specialized software (Shkedy, 2020).

In order to assure accurate measurement of progress and outcomes, the treatment plan must utilize measurable goals in objective and measurable terms based on standardized assessments that address the behaviors and impairments for which the intervention is to be applied (Maglione, 2012). The use of standardized assessments in a systematic and repeated manner is critical to the proper and consistent measurement of an individual’s response to treatment. Standardized assessments, as opposed to non-standardized assessments, are important because standardized assessments have been demonstrated to be consistent, reliable, and widely available. Furthermore, many have been validated for clinical accuracy as well. The use of standardized assessments early in the course of treatment, preferably before initiating treatment and at regularly scheduled intervals thereafter, provides information about any impact of treatment on developmental trajectory, especially documenting improvement. Examples of widely accepted and used standardized assessments include the VB-MAPP and the Vineland. These types of assessments usually consist of multiple sets of questions focusing on a variety of different developmental areas including, physical, language, social, and learning, and are intended to provide a clinical picture of an individual at a particular point in time.

The assessments characteristic of ABT can be classified into 3 types. A behavior identification assessment is used to identify behavioral issues that may be targeted for specific interventional treatment. There are many different assessment tools available for this type of assessment, and utilization of such a tool is critical for the proper identification and evaluation of behavioral issues. Examples of such tools include the VB-MAPP and the Vineland. Another assessment that may be required is a behavior identification supporting assessment. This type of assessment is used in the identification and evaluation of disruptive behaviors such as repetitive gestures, head banging, angry or violent outbursts, etc. According to the Council of Autism Service Providers (CASP) document titled, Applied Behavior Analysis Treatment for Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2014), this initial assessment should take approximately 20 hours. Additionally, these assessments may need to be repeated during the treatment period, but are likely to take considerably less time to complete when repeated. A behavior identification supporting assessment may be needed to further assess and characterize disruptive behaviors in order to understand social or environmental triggers of disruptive behaviors. Safety is very important. The environment in which these types of assessments are conducted should be carefully controlled, including the persons present at the time of evaluation. This is important in order to control for potential confounding elements that may interfere with proper assessment. Additionally, because aggressive or violent behaviors are often the types of disruptive behaviors for which this type of assessment is needed, there may be considerably risk to those present during the assessment period. In order to control for possible risk of harm, the assessment should be conducted in an environment that is away from areas that put others at unnecessary risk.

According to the BACB’s 2014 guideline, comprehensive ABT should include one-on-one treatment with a certified or licensed physician, qualified healthcare provider, or ABT technician of between 30 to 40 hours per week. This recommendation is joined by the recommendations made in guidelines addressing non-medical interventions published by the Health Resources and Services Administration (HRSA, Maglione, 2012), which states that “Children with ASD should be actively engaged in comprehensive intervention for a minimum of 25 hours per week throughout the year.” They support this with the comment that “the vast majority of high-quality behavioral interventions found in the literature required 20 to 40 hours of treatment per week.” A retrospective analysis of data on children with ASD found a statistical relationship between longer treatment duration and greater treatment intensity and skills acquisition (Linstead, 2017a; Linstead, 2017b). This analysis, however, did not determine the optimal number of treatment hours per week.

Comprehensive treatment, including ABT, refers to treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypical actions are also typically the focus of treatment (Maglione, 2012). Comprehensive ABT treatment may be referred to as adaptive behavior treatment or adaptive behavior treatment with protocol modification.                                                                 

Comprehensive ABT may involve several additional focused treatment methods tailored to address specific aspects of the individual’s condition. According to the BACB’s guidelines, focused treatments generally involve between 10 and 25 hours per week. One type of focused treatment is group adaptive behavior treatment, which targets maladaptive behaviors and skill deficits in a group setting. According to the HRSA, such group therapy has been found to be especially effective in older children (Maglione, 2012). Another type of focused treatment is family adaptive behavior treatment guidance, which is tended to provide instruction to a parent, guardian, or other caregiver in the treatment protocols designed to reduce maladaptive behaviors and increase generalization of acquired skills. Multiple-family group adaptive behavior treatment guidance is intended for the same purpose, but the goal is to train a group of parents, guardians, or caregivers together. These types of family-oriented therapies are recommended in HRSA guidelines (Maglione, 2012). Adaptive behavior treatment with protocol modification is intended to focus on the treatment of specific destructive behaviors such as gesturing or aggression.

Many of the treatments utilized in ABT are conducted by behavior analysts and technicians who may not be licensed, depending upon the laws and regulatory requirements of the area in which they are practicing. Supervision of behavior analysts and technicians by a licensed or certified professional is a requirement in the 2014 BACB guidelines, which states 2 hours of supervision for every 10 hours of direct treatment is the general standard of care.

The continuation of ABT is based upon the individual’s continuing to meet the criteria used to qualify the initial course of treatment. Additionally, is it critical that the individual’s person-centered treatment plan be updated, generally every 6 months, or as required by a state mandate, to provide adequate track of the individual’s progress. Assessments and interventions should suggest changes in the treatment plan because these evaluations and interventions are particularly intense and indicated when behavior poses a safety risk. The person-centered treatment plan should include age-specific and impairment appropriate goals and measures of progress as well as measures of the progress made with social skills, communication skills, language skills, adaptive functioning, and specific behaviors or deficits targeted. The measurement of progress in social skills, communication skills, language skills, and adaptive functioning should be measured by standard scores using standardized assessments no less frequent than every 2 years.

In 2021, Rodgers and colleagues published an individual participant meta-analysis on the impact of ABA for individuals with a diagnosis of autism. The analysis included 491 participants from 10 randomized or non-randomized controlled studies. The Vineland was used as an assessment tool in all 10 studies. In a meta-analysis, the investigators found a statistically significant benefit of ABA compared with a control intervention at 2 years (mean difference [MD], 7.00; 95% confidence interval [CI], 1.95 to 12.06), but not at 1 year (MD: 2.93; 95% CI, -1.90 to 7.76). Follow-up longer than 2 years was only available in 1 study and thus data could not be pooled for this outcome.

In 2023, Eckes and colleagues published a systematic review and meta-analysis of studies comparing comprehensive ABA-based interventions to a control intervention and with at least 5 participants per group. Eleven studies with a total of 632 participants were included. Studies varied in intervention intensity and duration, control intervention and outcome measures. In a meta-analysis of post-treatment improvement measures, the investigators found a statistically significant improvement after ABA-based treatment compared to control interventions (9 studies, SMD [standardized mean difference], 0.37, 95% CI, 0.03 to 0.70). There was also more improvement in intellectual functioning in the intervention compared with control groups (8 studies, SMD, 0.51, 95% CI, 0.09 to 0.92). The authors did not find statistically significant differences in post-treatment scores on language ability or symptom severity or parental stress. The meta-analysis is limited by methodological limitations of the included studies; for example, only 1 study was randomized, there was no participant or parent blinding in any study and outcome assessment was blinded in only 1 study.

The benefit of ABT in the absence of clinically significant developmental progress has not been demonstrated in the peer-reviewed published literature. When no measurable benefit has been discerned through accepted and validated measurement tools, the use of ABT is not warranted.  

There is no published literature demonstrating a benefit of ABT for conditions other than ASD and there are no clinical practice guidelines recommending ABT for non-ASD indications.

Note: State mandates or certificate language may define these terms more or less broadly than below; consult applicable mandates and certificates when applying this guideline.

Adaptive Behavior Treatment (ABT):

Behavioral and developmental interventions that systematically manage instructional and environmental factors or the consequences of behavior that have been shown to be clinically effective through research published in peer reviewed scientific journals and based upon randomized, quasi-experimental, or single subject designs. (General Assembly of North Carolina, 2015)

Applied Behavior Analysis (ABA):

ABA has been defined as “the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior.” The use of ABA methods to treat symptoms of ASD suggests that behaviors exhibited can be altered by programmatically reinforcing skills related to communication and other skill acquisition. Thus, ABA treatments may target development of new skills (eg, social engagement) and/or minimize behaviors (eg, aggression) that may interfere with a child’s progress (Hyman, 2020).

Assessment instruments: Specialized and standardized diagnostic test used to evaluate an individual’s performance in specific areas of functioning such as those recommended in the guidelines of the AAP, AAN and the AACAP (e.g., learning and communications skills, social interaction, etc.).

Autism spectrum disorder: A collection of associated developmental disorders that affect the parts of the brain that control social interaction and verbal and non-verbal communication.

Behavior modification: A therapy type that is designed to create new behavior patterns in people through intensive and frequent feedback using a reward, non-reward system.

Developmental, Individual Difference, Relationship-based (DIR^®/Floortime^™) Model:

[DIR/Floortime) is a framework that helps clinicians, parents and educators conduct a comprehensive assessment and develop an intervention program tailored to the unique challenges and strengths of children with Autism Spectrum Disorders (ASD) and other developmental challenges. The objectives of the DIR^®/Floortime^™ Model are to build healthy foundations for social, emotional, and intellectual capacities (Greenspan, 2022). A systematic review of the published literature on DIR/Floortime has been published by Boshoff and colleagues in 2020.

Developmental and relationship-based models: interventional approaches for children with ASD that focus on teaching skills that are essential to development (for example, social communication, emotional relationships, cognitive abilities). Examples of developmental models include the Early Start Denver model and Developmental Individual Difference Relationship-based approach (DIR or Floortime).

Educational interventions: Learning interventions that assist children with obtaining knowledge and communication through speech, sign language, writing and other methods and social skills. Note: Many benefit contracts exclude coverage for services that are educational in nature.

Early Start Denver Model (ESDM):
The ESDM is an approach to treating children with ASD that is includes elements of ABA and may also include non-ABA components such as speech and occupational therapy. ESDM has targeted children as young as 12 months of age. It was developed by Dawson and Rogers and has been studied in randomized trials (Dawson, 2010; Rogers 2012).

Oversight/supervision of treatment: ABT is usually conducted by many different individuals, all of whom are tasked with implementing a treatment plan created by a licensed or certified behavioral analyst. To assure that the treatment plan is being properly and effectively implemented, the licensed or certified provider is required to conduct regular direct supervision sessions of the individuals conducting the ABT treatments specified by the treatment plan for the individual with an autism spectrum disorder.

Qualified health care professional: An individual who has earned the appropriate education, training, certifications and/or licensure in a field related to the treatment of autism and is considered qualified under the laws of their state to be qualified to oversee ABT.

Visual Communication Analysis (VCA):

VCA is an application of Self-Determination Theory (SDT). SDT is a theory of intrinsic motivation that is founded on three main tenets: autonomy, competence, and relatedness (Deci & Ryan, 1985). Researchers Deci and Ryan (1985 & 2000) found conditions that support an individual’s experience of autonomy, competence, and relatedness tend to foster a high quality of motivation and engagement for activities, including enhanced performance, persistence, and creativity. As a result, instead of using an external reward to get a child to perform a task, VCA creates conditions that support the child’s experience of autonomy, competence, and relatedness in order for them to be intrinsically motivated to complete tasks. Within the VCA framework, the use of external rewards or punishment is heavily disfavored and never utilized. VCA gives children a variety of choices when learning in order to develop their intrinsic motivation, which is reinforced through presumed competence (Shkedy, 2020).

Peer Reviewed Publications:

1. Boshoff K, Bowen H, Paton H, et al. Child development outcomes of DIR/Floortime TM-based programs: A systematic review. Can J Occup Ther. 2020; 87(2):153-164.
2. Cohen H, Amerine-Dickens M, Smith T. Early intensive behavioral treatment: replication of the UCLA model in a community setting. J Dev Behav Pediatr. 2006; 27(2 Suppl):S145-155.
3. Dawson G, Rogers S, Munson J, et al. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010; 125(1):e17-e23.
4. Eckes T, Buhlmann U, Holling HD, et al. Comprehensive ABA-based interventions in the treatment of children with autism spectrum disorder - a meta-analysis. BMC Psychiatry. 2023; 23(1):133.
5. Eikeseth S, Smith T, Jahr E, Eldevik S. Intensive behavioral treatment at school for 4- to 7-year-old children with autism. A 1-year comparison controlled study. Behav Modif. 2002; 26(1):49-68.
6. Eldevik S, Eikeseth S, Jahr E, Smith T. Effects of low-intensity behavioral treatment for children with autism and mental retardation. J Autism Dev Disord. 2006; 36(2):211-224.
7. Gutstein, SE, Burgess AF, Montfort K. Evaluation of the relationship development intervention program. Autism. 2007; 11(5):397-411.
8. Howard JS, Sparkman CR, Cohen HG, et al. Comparison of intensive behavior analytic and eclectic treatments for young children with autism. Res Dev Disabil. 2005; 26(4):359-383.
9. Hyman SL, Levy SE, Myers SM; Council on children with disabilities, section on developmental and behavioral pediatrics. Identification, evaluation and management of children with autism spectrum disorder. Pediatrics. 2020; 145(1):e20193447.
10. Linstead E, Dixon DR, French R, et al. Intensity and learning outcomes in the treatment of children with autism spectrum disorder. Behav Modif. 2017a: 41(2):229-252.
11. Linstead E, Dixon DR, Hong E, et al. An evaluation of the effects of intensity and duration on outcomes across treatment domains for children with autism spectrum disorder. Transl Psychiatry. 2017b: 7(9):e1234.
12. McEachin JJ, Smith T, Lovaas OI. Long-term outcome for children with autism who received early intensive behavioral treatment. Am J Mental Retard. 1993; 97(4):359-372.
13. Rodgers M, Simmonds M, Marshall D, et al. Intensive behavioural interventions based on applied behaviour analysis for young children with autism: An international collaborative individual participant data meta-analysis. Autism. 2021; 25(4):1137-1153.
14. Sallows GO, Graupner TD. Intensive behavioral treatment for children with autism: four-year outcome and predictors. Am J Ment Retard. 2005; 110(6):417-438.
15. Sheinkopf SJ, Siegel B. Home-based behavioral treatment of young children with autism. J Autism Dev Disord. 1998; 28(1):15-23.
16. Shkedy G , Shkedy D, Sandoval-Norton AH et al. Visual communication analysis (VCA): Applying self-determination theory and research-based practices to autism, Cogent Psychology. 2020; 7(1):1803581.
17. Simpson RL. ABA and students with autism spectrum disorders: issues and considerations for effective practice. Focus on Autism and Other Dev Disabil. 2001; 16(2):68-71.
18. Smith T, Groen AD, Wynn JW. Randomized trial of intensive early intervention for children with pervasive developmental disorder. Am J Ment Retard. 2000; 105(4):269-285.
19. Strain PS, Schwartz I. ABA and the development of meaningful social relations for young children with autism. Focus on Autism and Other Dev Disabil. 2001; 16(2):120-128.

Government Agency, Medical Society, and Other Authoritative Publications:

1. 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.aacap.org/aacap/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx. Accessed on October 13, 2023.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision. DSM-5-TR. American Psychiatric Association. Washington, DC. February 2022.
3. Council of Autism Service Providers. Applied behavior analysis treatment for Autism Spectrum Disorder: Practice guidelines for healthcare funders and managers. Second edition. Available at: https://casproviders.org/asd-guidelines/  Last assessed on October 13, 2023.
4. Burrows K. The Canadian Paediatric Society Mental Health and Developmental Disabilities Committee. Position statement: Early intervention for children with autism. Paediatr Child Health. 2004; 9(4):267-270.
5. Center for Health Services and Policy Research, British Columbia Office of Health Technology Assessment, Autism and Lovaas treatment: A systematic review of effectiveness evidence, July 2000.
6. Dawson G, Rogers S, Munson J et al. Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010; 125(1):e17-23.
7. Filipek PS, Accardo PJ, Ashwal S, et al. American Academy of Neurology and the Child Neurology Society. 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. 2000; 55(4):468-479. Guideline-reaffirmed 07/28/2006.
8. Greenspan SI, Brazelton TB, Solomon R, et al. Guidelines for early identification, screening, and clinical management of children with autism spectrum disorders. Pediatrics. 2008; 121(4):828-830.
9. Greenspan, S. and Weider, S. DIR^® / Floortime^™ Model, Available at: https://www.stanleygreenspan.com/swf/The%20DIR%20Floortime%20Model.pdf . Accessed on September 12, 2022.
10. General Assembly of North Carolina. Senate Bill 676: Proposed Committee Substitute S676-PCS35270-TK-34. 2015. Available at: https://www.ncleg.gov/. Accessed October 13, 2023.
11. Maglione MA, Gans D, Das L, et al.; Technical Expert Panel; HRSA Autism Intervention Research – Behavioral (AIR-B) Network. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012; 130(Suppl 2):S169-178.
12. Pearson Education, Inc. Vineland Adaptive Behavior Scales, Third Edition (Vineland-3). Available at: http://www.pearsonclinical.com/psychology/products/100000668/vineland-adaptive-behavior-scales-second-edition-vineland-ii-vineland-ii.html. Accessed on October 13, 2023.
13. 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. 2018;(5):CD009260.
14. Rogers SJ, Estes A, Lord C, et al. Effects of a brief Early Start Denver model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: a randomized controlled trial, J Am Acad Child Adolesc Psychiatry. 2012; 51(10):1052-1065.
15. Volkmar F, Cook EH Jr, Pomeroy J, et al. Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues. J Am Acad Child Adolesc Psychiatry. 1999; 38(12 Supp):32S-54S.
16. Volkmar F, Siegle M, Woodbury-Smith M, et al.; 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, 2014; 53(2):237-257.
17. Zwaigenbaum L, Bauman ML, Choueiri R, et al. Early Intervention for Children with Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research. Pediatrics. 2015a; 136(Suppl 1):S60-S81.
18. Zwaigenbaum L, Bauman ML, Stone WL, et al Early Identification of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics. 2015b; 136 (Suppl 1):S10-40.

1. National Institute of Neurological Disorders and Stroke. Pervasive Developmental Disorders Available at: https://www.ninds.nih.gov/Disorders/All-Disorders/Pervasive-Developmental-Disorders-Information-Page. Accessed on October 13, 2023.
2. National Library of Medicine. Medical Encyclopedia, Autism spectrum disorder. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm. Accessed on October 13, 2023.
3. The Nemours Foundation. Autism. Available at: http://kidshealth.org/parent/medical/learning/pervasive_develop_disorders.html. Accessed on October 13, 2023.

Adaptive Behavioral Treatment (ABT)
Applied Behavioral Analysis (ABA)
Asperger’s Syndrome
Autism
Early Intensive Behavior Intervention (EIBI)
Early Start Denver Model (ESDM)
Floortime
Intensive Behavior Intervention (IBI)
Lovaas Therapy
Pervasive Developmental Disorder (PDD)
Visual Communication Analysis (VCA)

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.

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