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1 Applied Behavir Analysis fr the Treatment f Autism Original Effective Date: December 2016 Reviewed: December 2016 Revised: August 2017 This plicy applies t all prducts unless specific cntract limitatins, exclusins r exceptins apply. Please refer t the member s benefit certificate language fr benefit availability. Managed care guidelines related t referral authrizatin, precertificatin f inpatient hspitalizatin, hme health, hme infusin and hspice services apply. Descriptin Applicability: Federal Emplyee Prgram (FEP) Nte: The member s benefit plan determines cverage, applied behavir analysis therapy fr all ther indicatins except fr the treatment f autism will be cnsidered a nn-cvered benefit. Prviders will need t cmplete the fllwing frms fr prir apprval requests: The Prir Apprval Frm will need t be cmpleted fr all prir apprval requests fr ABA therapy fr initial and nging therapy services. Prir Apprval Frm: This frm is t be used fr submitting all prir apprval requests fr ABA therapy services. Cntracting prviders may use the nline Utilizatin Management Tl fr submitting a prir apprval request. After initial assessment and develpment f individualized treatment plan is cmpleted, the fllwing frms will need t be cmpleted fr all prir apprval requests t determine medical necessity fr nging ABA therapy services. ABA Therapy Individualized Treatment Plan Dcument ABA Therapy Prgress Reprt Dcument Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 1

2 Autism Spectrum Disrder The diagnsis f autism spectrum disrder has been validated by a dcumented cmprehensive assessment demnstrating the presence f the fllwing diagnstic criteria fr autism spectrum disrder (ASD) based n The Diagnstic and Statistical Manual f Mental Disrders (DSM-5): A. Persistent deficits in scial cmmunicatin and scial interactin acrss multiple cntexts, as manifested by the fllwing, currently r by histry (examples are illustrative, nt exhaustive): 1. Deficits in scial-emtinal reciprcity, ranging, fr example frm abnrmal scial apprach and failure f nrmal back-and-frth cnversatin; t reduce sharing f interests, emtins, r affect; t failure t initiate r respnd t scial interactins. 2. Deficits in nnverbal cmmunicative behavirs used fr scial interactin, ranging, fr example, frm prly integrated verbal and nnverbal cmmunicatin; t abnrmalities in eye cntact and bdy language r deficits in understanding and use f gestures; t a ttal lack f facial expressins and nnverbal cmmunicatin. 3. Deficits in develping, maintaining, and understanding relatinships, ranging, fr example, frm difficulties adjusting behavir t suit varius scial cntexts; t difficulties in sharing imaginative play r in making friends; t absence f interest in peers Specify Current Severity: Severity is based n scial cmmunicatin impairments and restricted, repetitive patterns f behavir. (See belw) B. Restricted, repetitive patterns f behavir, interests, r activities, as manifested by a least tw f the fllwing, currently r by histry (examples are illustrative, nt exhaustive): 1. Steretyped r repetitive mtr mvements, use f bjects r speech (e.g., simple mtr steretypes, lining up tys r flipping bjects, echlalia, idisyncratic phrases). 2. Insistence n sameness, inflexible adherence t rutines, r ritualized patterns f verbal r nnverbal behavir (e.g., extreme distress at small changes, difficulties with transitins, rigid thinking patterns, greeting rituals, need t take same rute r eat same fd every day). 3. Highly restricted, fixated interests that are abnrmal in intensity r fcus (e.g., strng attachment t r preccupatin with unusual bjects, excessively circumscribed r perseverative interests). 4. Hyper r hyp-reactivity t sensry input r unusual interest in sensry aspects f the envirnment (e.g., apparent indifference t pain/temperature, adverse respnse t specific sunds r textures, excessive smelling r tuching f bjects, visual fascinatin with lights r mvement). Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 2

3 Specify current severity: Severity is based n scial cmmunicatin impairments and restricted, repetitive patterns f behavir. (See belw) C. Symptms must be present in the early develpment perid (but may nt becme fully manifested until scial demands exceed limited capacities, r may be masked by learned strategies in later life). D. Symptms cause clinically significant impairment in scial, ccupatinal, r ther imprtant areas f current functining E. These disturbances are nt better explained by intellectual disability (intellectual develpment disrder) r glbal develpmental delay. Intellectual disability and autism spectrum disrder frequently c-ccur; t make cmrbid diagnses f autism spectrum disrder and intellectual disability, scial cmmunicatin shuld be belw that expected fr general develpmental level. Severity Levels fr Autism Spectrum Disrder Severity Level Scial Cmmunicatin Restricted, Repetitive Behavirs Level 3 Requiring very substantial supprt Level 2 Requiring substantial supprt Severe deficits in verbal and nnverbal scial cmmunicatin skills cause severe impairments in functining, very limited initiatin f scial interactins, and minimal respnse t scial vertures frm thers. Fr example, a persn with few wrds f intelligible speech wh rarely initiates interactin and, when he r she des, makes unusual appraches t meet needs nly and respnds t nly very direct scial appraches. Marked deficits in verbal and nnverbal scial cmmunicatin skills; scial impairments apparent even with supprts in place; limited initiatin f scial interactins; and reduced r abnrmal respnses t scial vertures frm thers. Fr example, a persn wh speaks simple sentences, whse interactin is limited t narrw special interests, and wh has markedly dd nnverbal cmmunicatin. Inflexibility f behavir, extreme difficulty cping with change, r ther restricted/repetitive behavirs markedly interfere with functining in all spheres. Great distress/difficulty in changing fcus r actin. Inflexibility f behavir, difficulty cping with change, r ther restricted/repetitive behavirs appear frequently enugh t be bvius t the casual bserver and interfere with functining in a variety f cntexts. Distress and/r difficulty changing fcus r actin. Level 1 Requiring supprt Withut supprts in place, deficits in scial cmmunicatin cause nticeable impairments. Difficulty initiating scial interactins, and clear examples f atypical r unsuccessful respnses t Inflexibility f behavir causes significant interference with functining in r mre cntexts. Difficulty switching between Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 3

4 Severity Levels fr Autism Spectrum Disrder Severity Level Scial Cmmunicatin Restricted, Repetitive Behavirs scial vertures f thers. May appear t activities. Prblems f rganizatin have decreased interest in scial and planning hamper independence. interactins. Fr example, a persn wh is able t speak in full sentences and engages in cmmunicatin but whse tand-fr cnversatin with thers fails, and whse attempts t make friends are dd and typically unsuccessful. Applied Behavir Analysis (ABA) Strategies Applied Behavir Analysis (ABA), is a behaviral therapy interventin funded by Ivar Lvaas and clleagues in the 1960 s and uses varius strategies t address behaviral prblems prevalent in individuals with autism spectrum disrders (ASD). The Lvaas mdel f ABA suggests that treatment shuld begin by the age f three years ld, the treatment may be intensive, and must invlve the ABA techniques aimed t develp scial and cmmunicatins skills which shuld be prvided in a 1:1 treatment frmat. Discrete Trial Teaching is a methd f teaching in simplified and structured steps. Instead f teaching an entire skill in ne g, the skill is brken dwn and built-up using discrete trials that teach each step ne at a time. Pivtal Respnse Training (PRT) targets pivtal areas f a child s develpment, such as mtivatin, respnsivity t multiple cues, self-management and scial initiatins. By targeting these behavirs the results are t imprve cmmunicatin, scial and behaviral dmains. Mtivatinal prcedures including child chice, task variatin, interspersing maintenance and acquisitin tasks, rewarding attempts and use f direct natural reinfrcers that are incrprated t make the interventin mre effective and efficient. The gal f PRT is t mve the child with ASD twards a mre typical develpmental trajectry thrugh individualized interventin bjective based n the child s needs. Incidental teaching is behavirally based instructin where the interactin between the adult and child ccurs in the cntext f a natural situatin where the child expresses an interest in smething and the adult respnds with prmpts and praise. Treatment and Educatin f Autistic and Cmmunicatin Handicapped Children (TEACCH) is nt a curriculum, but instead is a framewrk t supprt achievement f educatinal and therapeutic gals. Structured TEACCHing is an array f teaching r treatment principles and strategies based n the learning characteristics f individuals with ASD, including strengths in visual infrmatin prcessing, and difficulties with scial cmmunicatin, attentin, and executive functin. The gal f Structured TEACCHing is t prmte meaningful engagement in activities, flexibility, independence and self-efficacy (t succeed in specific situatins r accmplish a task). Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 4

5 Applied Behavir Analysis Cntrlled clinical trials f ABA therapy rarely include children yunger than 18 mnths f age. Withut such research, there is insufficient evidence t evaluate the effectiveness f ABA therapy in children yunger than age 18 mnths. Als, there have been few studies cnducted t assess treatment appraches fr adlescents and yung adults (ages 13 t 30) with autism spectrum disrder (ASD), and as such there is very little evidence available fr specific treatment appraches in this ppulatin. Of the small studies available, mst were f pr quality. Behaviral, educatinal, and adaptive/life skills studies were typically small and shrt term and suggested sme ptential imprvements in scial skills and functinal behavir. There is lack f evidence t supprt the use f medical r allied health interventins in the adlescent and yung adult ppulatin. The medical studies that have been cnducted fcused n the use f medicatins t address specific challenging behavirs, including irritability and aggressin, fr which effectiveness in this age grup is largely unknwn and inferred frm studies including mstly yunger children. Amng the methdlgies/strategies available fr the management f autism spectrum disrder, applied behavir analysis (ABA) is the mst studied treatment mdality in the field. It is generally believed that ABA is the prcess f applying interventins that are based n the principles f learning (e.g. psitive reinfrcement) derived frm research t systematically change behavir. It can als be used t teach new skills and demnstrate that the interventins used are respnsible fr the bservable imprvements in behavir. ABA methds are reprtedly used t replace maladaptive, interfering behavirs with mre desirable, adaptive behavirs and t narrw the cnditins under which maladaptive, interfering behavirs ccur. In additin, ABA is believed t teach new skills thrugh implicit instructin and repetitin, generalize behavirs t new envirnments r situatins, and maintain learned behavirs. Fr example, clear instructin with assistance (e.g. demnstratin, prmpting) is given t the individual, and when the individual gives a crrect respnse, the prvider gives psitive reinfrcement. ABA interventins require a demnstratin f the events that are respnsible fr the ccurrence, r nn-ccurrence f behavir. Applied behavir analysis (ABA) uses methds f analysis that yield cnvincing, reprducible, and cnceptually sensible demnstratins f hw t accmplish specific behavir changes. These behavirs are evaluated within relevant settings such as schls, hmes and the cmmunity prgrams based upn ABA methdlgies. This prcess includes the fllwing cmpnents: Selectin f interfering behavir r behaviral skill deficit Identificatin f gals and bjectives Establishment f a methd f measuring target behavirs Evaluatin f the current levels f perfrmance (baseline) Design and implementatin f the interventins that teach new skills and/r reduce interfering behavirs Cntinuus measurement f target behavirs t determine the effectiveness f the interventin(s) Onging evaluatin f the effectiveness f the interventin, with mdificatins made as necessary t maintain and/r increase bth the effectiveness and the efficiency f the interventin. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 5

6 Types f applied behavir analysis interventins include but are nt limited t the fllwing: Early Start Denver Mdel (ESDM); Picture Exchange Cmmunicatin System (PECS); Functinal Cmmunicatin Training and Verbal Behavir; Develpmental, Individual Difference, Relatinship-based Mdel (DIR); and Scial Cmmuncatin, Emtinal Regulatin, & Transactinal Supprt (SCERTS). Gals f Therapy Overall gal f treatment is t: Maximize functining Mve the child tward independence Imprve the quality f life fr the child and family Specific gals are t: Imprve scial functining and play skills Imprve cmmunicatin skills (bth functinal and spntaneus) Imprve adaptive skills Decrease nnfunctinal r negative behavirs Prmte academic functining and cgnitin Measuring Behavir When measuring behavir, there are bth dimensins f behavir and quantifiable measures f behavir. In applied behavir analysis, the quantifiable measures are a derivative f the dimensins. These dimensins are repeatability, tempral extent, and tempral lcus. Repeatability: respnse classes ccur repeatedly thrughut time i.e. hw many times the behavir ccurs. Cunt: is the number f ccurrences in behavir Rate/frequency: is the number f instances f behavir per unit f time Celeratin: is the measure f hw the rate changes ver time Tempral Extent: this dimensin indicates that each instance f behavir ccupies sme amunt f time i.e. hw lng the behavir ccurs. Duratin: is the amunt f time in which the behavir ccurs Tempral Lcus: each instance f behavir ccurs at a specific pint in time i.e. when the behavir ccurs. Respnse latency: is the measure f elapsed time between the nset f a stimulus and the initiatin f the respnse Interrespnse time: is the amunt f time that ccurs between tw cnsecutive instances f a respnse class. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 6

7 Individuals with autism spectrum disrder (ASD) have varying degrees f impairment in scial and behavir functin. Management f ASD is individualized accrding t age and specific needs. Therefre, each individual requires an individualized treatment plan utlining the services including variatins in the duratin and intensity including applied behavir analysis. Cmpnents f ABA Therapy include the fllwing: An initial assessment thrugh bservatins that fcus n strengths and weaknesses f the individual. The individualized treatment plan which include the identificatin f target behavirs, with individualized treatment gals that are guided by the data frm the assessment and are defined in bservable terms. A written treatment plan r set f instructins fr teaching each behavir and/r skill, develped by a prfessinal prvider A curriculum that fcuses n the fllwing: Breaking dwn skills int manageable pieces Building upn skills s that an individual can learn in a natural envirnment Teaching the individual t cmbine skills acquired in mre cmplex ways Training fr the individual s parent(s) and/r caregiver(s) t implement the treatment plan cnsistently bth within and utside frmal treatment sessins. Dcumented assessments and adjustments t the treatment plan when required. Dcumentatin f the individual s prgress is in measurable utcmes, using direct bservatinal measurement methds. As prgress is made, guidance is systematically reduced. N reinfrcement fr prblem behavirs Management f autism spectrum disrder (ASD) requires a multidisciplinary apprach which may include the fllwing service prviders: Bard Certified Behavir Analysts: Cnduct behaviral assessments and prvide interpretatins f the results f such assessments. They design and supervise behavir analytic interventins t address bth the acquisitin f skills and the reductin f challenging behavirs. Many bard certified behavir analysts als hld licenses r certificatins in ther disciplines (e.g. psychlgy). Cunseling/Psychlgical Service Prviders: These individuals may include clinical psychlgists, cunseling psychlgists, marriage and family cunselrs, scial wrkers, psychiatric nurses r related prfessinals, as well as certified behavir analysts. They may prvide parent training r supprt, scial skills grups, clinical behavir therapy, play therapy. In sme cases, the invlvement f these prviders may be restricted t cnducting evaluatins and making recmmendatins. Early Interventin Prviders: Early interventin prviders seek t address the needs f children suspected f disabilities frm birth t three years f age. In sme states, early interventin is defined as birth t five years f age. As is the case with special educatin services, children in this age grup must meet eligibility criteria in rder t qualify fr services. Pririties in early interventin ften include addressing deficits in cgnitive, language, mtr, scial, play and self-care skills, reducing the gap between the child s skills and thse f his/her typically develping agemates, and preparing the child fr Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 7

8 public schl. Early interventin prviders deliver an array f services t bth the child and the family and these shuld be clearly identified n a child s Individualized Family Services Plan (IFSP). General Educatin Teachers: General educatin teachers wrk with students in preschl, elementary and secndary schls. They prvide services t large grups f students althugh class sizes range frm schl t schl. Given the federal mandate that children participate t the fullest extent pssible in least restrictive settings, children with autism and related disrders have cnsiderable cntact with general educatin teachers. This may invlve an all-day placement r parts f the day (selected carefully by the team). A child with autism may participate in general educatin classrm r classrms with r withut the supprt f a paraprfessinal. Special Educatin Teachers: In cntrast t general educatin teachers, special educatin teachers fcus upn meeting the unique educatinal needs f children with identified disabilities such as autism. They prvide an array f services which shuld be clearly identified n a student s Individualized Educatin Plan (IEP). Many special educatin teachers either wrk with students with autism in self-cntained classrms r in resurce rms with the distinctin related t the amunt f time the child spends with the special educatin teacher. In additin, the special educatin teacher typically supervises the effrts f paraprfessinals. When a student is determined t be eligible fr special educatin services, the special educatin teacher ften assumes a case management rle t help crdinate the services f varius prviders n the multidisciplinary team. Paraprfessinals: The gal f paraprfessinal teaching staff is t supprt the effrts f the teachers. Their invlvement varies widely with respect t bth the amunt and nature f cntact. Fr example, paraprfessinals may be invlved in ne t ne teaching, small grup instructin, and shadwing and supprting the child with autism in a general educatin classrm. Given the rle they serve and the amunt f direct cntact that they have with their students, it is imperative that they receive the training, mentrship, and supervisin necessary t maximize their skills and cmpetencies. Occupatinal Therapists (OT): Occupatinal therapists prvide training in daily living skills such as dressing and hygiene, as well as fine mtr skills related t hlding bjects, handwriting, cutting and ther activities. Their treatments rely n the use f specific tasks r gal-directed activities designed t imprve the functinal perfrmance f an individual as it relates t the smaller muscle grups. They may als wrk n sitting, psture, and perceptual skills (i.e. recgnizing differences in clr, shape and size) and many ccupatinal therapists specialize in feeding and swallwing. Physical Therapists (PT): As is the case with ccupatinal therapists, physical therapists are als cncerned with imprving r restring physical functin; hwever, they fcus upn the larger muscle grups. They als use therapeutic exercises t reduce pain r imprve psture, lcmtin, strength, endurance, balance, crdinatin, jint mbility and range f mvement and flexibility. Exercises may be active r passive (i.e. perfrmed by the individual r perfrmed n the individual by the therapist r by specialized equipment) and are based upn bimechanical and neurphysilgic principles. Physical therapy des nt include adaptive physical educatin r dance therapy. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 8

9 Speech and Language Pathlgists (SLPs): Speech and language pathlgists are invlved in the treatment f cmmunicatin and speech impairments. Treatment areas may include muscle cntrl related t speech prductin, articulatin, prsdy, vcabulary develpment, receptive and expressive language skills, cnversatin skills, and scial pragmatics. Applied behavir analysis (ABA) therapy is typically prvided by a treatment team rather than individual prvider. Team is cmpsed f paraprfessinals (registered behavir technician (RBT)), wh are primarily respnsible fr the direct implementatin f skill acquisitin and behavir reductin plans develped by a bard certified BCBA/BCBA-D. They may als cllect data and cnduct certain types f assessments (e.g. stimulus preference assessments). The bard certified behavir analyst prfessinals (BCBA/BCBA-D), cnducts descriptive and systematic behavir assessments, including functinal analysis and prviders behavir analytic interpretatin and results. They als design and supervise behavir analytic interventins by the paraprfessinals and bard certified assistant behavir analysts (BCaBA). Behavir Analyst Certificatin Bard, Inc The Behavir Analyst Certificatin Bard, Inc (BABC) is a nnprfit 501(c)(3) crpratin that was established in 1998 t meet prfessinal credentialing needs identified by behavir analysts, gvernments and cnsumers f behavir analysis services. The BACB adheres t internatinal standards fr bards and grant prfessinal credentials. The BACB certificatin prcedures and cntent underg regular psychmetric review and validatin, pursuant t a jb analysis survey f the prfessin and standards established by cntent experts in the field. The Behavir Analyst Certificatin Bard s credentialing prgrams are accredited by the Natinal Cmmissin fr Certifying Agencies in Washingtn, DC. NCCA is the accreditatin bdy f the Institute fr Credentialing Excellence. BACB s Missin: Prtect cnsumers f behavir analysis services by systematically establishing, prmting and disseminating prfessinal standards. Behavir Analyst Certificatin Bard, Inc Credentials Bard Certified Behavir Analyst (BCAB, BCBA-D): The BCBA and BCBA-D are independent practitiners wh als may wrk as an emplyee r independent cntractrs fr an rganizatin. BCBA-D - are bard certified behavir analysts wh have earned a Dctrate Degree and the BCBA-D certificatin with all the training and experience requirements set frth by the Behaviral Analyst Certificatin Bard. BCBA are bard certified behavir analysts wh have earned a Master s Degree and the BCBA certificatin with all the training and experience requirements set frth by the Behavir Analyst Certificatin Bard. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 9

10 The BCBA r BCBA-D is primarily respnsible fr the fllwing: Cnducts descriptive and systematic behaviral assessments, including functinal analyses, and prvides behavir analytic interpretatins f the results. Designs and supervises behavir analytic interventins. Able t effectively develp and implement apprpriate assessment and interventin methds fr use in unfamiliar situatins and fr the range f cases. Seeks the cnsultatin f mre experienced practitiners when necessary. Teaches thers t carry ut ethical and effective behavir analytic interventins based n published research and designs and delivers instructin in behavir analysis. Supervise the wrk f Bard Certified Assistant Behavir Analysts (BCaBA) and thers wh implement behavir analytic interventins (Registered Behavir Technician (RBT)). Bard Certified Assistant Behavir Analyst (BCaAB) BCaBA is an undergraduate-level certificatin in behavir analysis. Prfessinals wh are certified at the BCaBA level may nt practice independently, but must be supervised by smene at the BCBA/BCBA-D level. In additin, BCaBAs can supervise the wrk f Registered Behavir Technicians, and thers wh implement behavir-analytic interventins. BCaBA - are bard certified assistant behavir analysts wh have earned a bachelr s degree and the BCaBA certificatin with all the training and experience requirements set frth by the Behavir Analyst Certificatin Bard. Registered Behavir Technician (RBT): The Registered Behavir Technician (RBT) is a paraprfessinal wh practices under the clse, nging supervisin f a BCBA r BCaBA. The RBT is primarily respnsible fr the direct implementatin f behavir analytic services. The RBT des nt design interventin r assessment plans. It is the respnsibility f the RBT supervisr t determine which tasks an RBT may perfrm as a functin f his r her training, experience and cmpetence. The BACB certificant supervising the RBT is respnsible fr the wrk perfrmed by the RBT n the cases they are verseeing. RBT must be at least 18 years f age, pssess a minimum f a high schl diplma r natinal equivalent, cmplete 40 hurs f training, pass RBT Cmpetency Assessment and pass the RBT exam. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 10

11 Treatment Plan Requirements Applied Behavir Analysis (ABA) prgrams must have an individualized dcumented treatment plan with clear written descriptins f treatment gals and bjectives that includes all f the fllwing: Diagnsis f autism spectrum disrder (ASD) cnsistent with the (DSM-5) criteria abve Age Identificatin and detailed descriptin f targeted symptms and behavirs. Targeted symptms and behavirs must be thse which are preventing the individual frm adequately participating in age apprpriate hme, schl r cmmunity activities, r that are presenting a safety risk t self, thers r prperty. The infrmatin shuld include but is nt limited t the fllwing: Cmmunicatin/language Scial/family interactins Behavirs interfere with functining/relatinships Repetitive restricted behavirs Disruptive/Aggressive r self-injurius behavirs; Behaviral targets (gals) defined by bjective baseline measurements, based upn clinical bservatin and tailred t the patient; Recrds frequency, rate, symptm intensity r duratin r ther bjective measures f baseline levels; Detailed descriptin f treatment mdality r mdalities and interventins fr each targeted symptm and behavir Describe behaviral interventin techniques apprpriate t the target behavir, reenfrces selected and strategies fr generalizatin f learned skills t fcus n the develpment f spntaneus scial cmmunicatin, adaptive skills and apprpriate behavirs; Treatment gals and measures f prgress fr each targeted symptm and behavir, with established timeframes fr achieving the gals; If applicable the plan fr cmmunicatin and crdinatin with ther prviders and agencies including but nt limited t day care, preschl, schl, early interventin services prvider(s) and/r ther allied health services (i.e. ccupatinal therapy, speech therapy, physical therapy and any ther applicable prviders) and include the fllwing: Types f therapy prvided; Number f therapies per week; Behavirs/deficits targeted; and Prgress related t treatment/services being prvided. This will reduce the likelihd f unnecessary duplicatin f services, the delivery f cnflicting interventins r instructins, and the prvisin f mre therapy hurs than the patient is able t tlerate r benefit frm; Parent(s) r caregiver(s) (active caretakers r legal guardians) are available and cmmitted t full participatin in the prgram, are engaged in training and will fllw thrugh n treatment recmmendatins beynd that prvided by the bard certified behavir analyst r prfessinal: Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 11

12 Detailed descriptin f interventins with parent(s) r caregiver(s) including the fllwing: Parental r caregiver educatin Training Caching Supprt Overall gals fr parent(s) r caregiver(s) Plan fr transferring interventins t the parent(s) r caregiver(s) Dcument the plan fr transitin thrugh the cntinuum f care t include interventins, services and settings invlving the parent(s) r caregiver(s), schl, state disability prgrams and thers as applicable; Dcuments the discharge criteria Measurable criteria fr cmpleting treatment, with prjected plan fr cntinued care after discharge frm ABA Ttal number f days per week and hurs per day f direct services t the patient and parent(s) r caregiver(s) t include duratin and lcatin f the requested ABA therapy; Licensure, certificatin and credentials f the prfessinals prviding services t the individual thrugh the Applied Behavir Analysis (ABA) Therapy Prgram. Evaluatin f Prgress Prgress is assessed and dcumented fr each targeted symptm and behavir, including prgress twards the defined gals, and including the same mde f measurement that were utilized fr baseline measurements f specific symptms and behavirs. When gals have been achieved, either new gals shuld be identified that are based n targeted symptms and behavirs which are preventing the individual frm adequately participating in age-apprpriate hme, schl r cmmunity activities, r that are presenting a safety risk t self, thers r prperty; r, the treatment plan shuld be revised t include a transitin t less intensive interventins. When there has been inadequate prgress re: targeted symptms and behavirs, r n demnstrable prgress within a six mnth perid, r specific gals have nt been achieved within the estimated timeframes, there shuld be an assessment f the reasn fr inadequate prgress r nt meeting the gals, and treatment interventins shuld be mdified r changed in rder t attempt t achieve adequate prgress. When there is cntinued absence f adequate imprvement r when prgress plateaus, and there is n reasnable expectatin f further prgress, the treatment plan shuld be revised t reflect a planned discntinuatin f ABA and referral t ther resurces as apprpriate. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 12

13 Dcumentatin Requirements The fllwing dcumentatin (nt an all inclusive list) may be requested and reviewed in making medical necessity determinatins fr applied behavir analysis (ABA) therapy: Cpy f the Applied Behavir Analysis individualized treatment plan. Applied behavir analysis therapy prgress reprt that dcuments the prgress f treatment gals fr the individual and als prgress related t the parent/caregiver gals, t include any prgress ntes. Any dcumented reprts cmpleted fr psychlgical indicatins and/r ther cmpleted testing. If applicable cpy f the patient s Individualized Educatin Prgram Plan (IEP). If applicable prgress ntes related t Early Interventin Plan r Pre-schl/Special Educatin Prgram r allied health services. Frequency, duratin and lcatin f the requested ABA therapy. Certificatin and credentials f the prfessinal(s) prviding the ABA therapy. Practice Guidelines and Psitin Statements American Academy f Pediatrics In 2012 the American Academy f Pediatrics issued the fllwing: Nnmedical Interventins fr Children with ASD: Recmmended Guidelines and Further Research Needs, which states that the TEP (Technical Expert Panel) cnsisting f practitiners, researchers, and parents agreed that children with ASD shuld have access t at least 25 hurs per week f cmprehensive interventin t address scial cmmunicatin, language, play skills and maladaptive behavir. They agreed that applied behaviral analysis, integrated behaviral/develpment prgrams, the Picture Exchange Cmmunicatin System, and varius scial skills interventins have shwn efficacy. Based n identified gaps, they recmmend further research fcus n assessment and mnitring f utcmes, addressing the needs f pre/nn-verbal children and adlescents, and identifying the mst effective strategies, dse and duratin t imprve specific cre deficits. The creatin f treatment guidelines and recmmendatins fr future research represents an effrt by leading experts t imprve access t services fr children with ASDs while acknwledging that research evidence has many gaps. Natinal Research Cuncil The Natinal Research Cuncil, ne f fur agencies that make up the Natinal Academies including the Institute f Medicine, recmmends that the educatinal services begin as sn as a child is suspected f having an ASD. The services shuld include a minimum f 25 hurs a week in which the child is engage in systematically planned, and develpmentally apprpriate educatinal activity tward identified bjectives. Natinal Autism Center (NAC) Natinal Standards Prject Phase 1 and Phase 2: Addressing the need fr evidence-based practice guidelines fr autism spectrum disrder (ASD). Its primary gal is t prvide critical infrmatin abut which interventins have been shwn t be effective fr individuals with ASD. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 13

14 The Natinal Standards Prject seeks t: Prvide the strength f evidence supprting educatinal and behaviral interventins that target the cre characteristics f these neurlgical disrders Describe the age, diagnsis, and skills/behavirs targeted fr imprvement assciated with interventin ptins Identify the limitatins f the current bdy f research n autism interventins Offer recmmendatins fr engaging in evidence-based practice fr ASD Wh benefits frm natinal standards? We believe that parents, caregivers, educatrs, and service prviders wh must make cmplicated decisins abut interventin selectin will benefit frm natinal standards Phase 1 f the Natinal Standards Prject: Phase 1 (NSP1) examined and quantified the level f research supprting interventins that target the cre characteristics f ASD in children, adlescents, and yung adults (under 22 years f age) n the autism spectrum Phase 2 f the Natinal Standards Prject: Phase 2 (NSP2) reviewed studies published between 2007 and February f As in the first iteratin f the Natinal Standards Prject, the fcus was an evaluatin f educatinal and behaviral interventin literature fr individuals with ASD. This review updated ur summary f ASD interventin literature fr children and yuth under age 22. We have updated ur riginal findings, added infrmatin, and evaluated whether any f the Emerging interventins in NSP1 had mved int the Established r Unestablished categries f NSP2. We als analyzed interventin utcme studies fr individuals ages 22 years and lder. Because the first phase f NSP fcused slely n interventins fr individuals under age 22, the NSP literature search fr individuals ages 22+ spanned several decades. The earliest interventin utcme study fr individuals ages 22+ was published in Results frm the NSP2 Research Findings Fr Children, Adlescents, and Yung Adults Under 22 Years f Age: There are 14 Established Interventins that have been thrughly researched and have sufficient evidence fr us t cnfidently state that they are effective. There are 18 Emerging Interventins that have sme evidence f effectiveness, but nt enugh fr us t be cnfident they are truly effective. There are 13 Unestablished Interventins fr which there is n sund evidence f effectiveness. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 14

15 Fr Adults Ages 22 and Older: There is ne Established Interventin that has been thrughly researched and has sufficient evidence fr us t cnfidently state that it is effective. There is ne Emerging Interventin that has sme evidence f effectiveness, but nt enugh fr us t be cnfident that it is truly effective. There are fur Unestablished Interventins fr which there is n sund evidence f effectiveness. Based n the findings and cnclusins f the NSP2, Behaviral Interventins is ne f the Established Interventins fr children, adlescents and yung adults under 22 years f age and als fr adults 22+ years. The Behaviral Interventins categry is cmprised f interventins typically described as antecedent interventins and cnsequent interventins. Antecedent interventins invlve the mdificatin f situatinal events that typically precede the ccurrence f target behavir. These alteratins are made t increase the likelihd f success r reduce the likelihd f prblems ccuring. Cnsequent interventins invlve making changes t the envirnment fllwing the ccurrence f a targeted behavir. Many f the cnsequent interventins are designed t reduce prblem behavir and teach functinal alternative behavirs r skills thrugh the applicatin f basic principles f behavir change. Skills Increased Higher cgnitive functins Mtr skills Academic, cmmunicatin, interpersnal, learning readiness, persnal respnsibility,play and self-regulatin Behavirs Decreased Sensry r emtinal regulatin Prblem behavirs Restricted, repetitive, nnfunctinal patterns f behavir, interests, r activity Established Interventins is defined as: Sufficient evidence is available t cnfidently determine that interventin prduces favrable utcmes fr individuals n the autism spectrum. That is, these interventins are established as effective. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 15

16 Prir Apprval Prviders will need t cmplete the fllwing frms fr prir apprval requests: The Prir Apprval Frm will need t be cmpleted fr all prir apprval requests fr ABA therapy fr initial and nging therapy services. Prir Apprval Frm: This frm is t be used fr submitting all prir apprval requests fr ABA therapy services. Cntracting prviders may use the nline Utilizatin Management Tl fr submitting a prir apprval request. After initial assessment and develpment f individualized treatment plan is cmpleted, the fllwing frms will need t be cmpleted fr all prir apprval requests t determine medical necessity fr nging ABA therapy services. ABA Therapy Individualized Treatment Plan Dcument ABA Therapy Prgress Reprt Dcument Plicy The intent f this medical plicy is t address applied behavir analysis (ABA) therapy fr the treatment f autism. Nte: The member s benefit plan determines cverage, applied behavir analysis therapy fr all ther indicatins except fr the treatment f autism will be cnsidered a nn-cvered benefit. Based upn evidenced based literature applied behavir analysis (ABA) therapy is an intensive treatment that is t be rendered face-t-face and n a 1:1 basis with the patient. Therefre, the fllwing will be cnsidered nt medically necessary r cntract exclusin: Grup therapy frmats (0366T, 0367T, 0371T, 0372T) Telemedicine frmats Parent/Caregiver supprt is expected t be a cmpnent f the applied behavir analysis (ABA) therapy prgram, as they will need t prvide additinal hurs f behaviral interventins. Hwever, parent supprt grups are cnsidered nt medically necessary r cntract exclusin. ABA Therapy Prvided Inpatient, Residential r Partial Hspitalizatin Settings If ABA therapy is being prvided as part f the treatment plan in an inpatient, residential r partial hspitalizatin setting, medical necessity at that level f care will be inclusive f this therapy, an additinal authrizatin specific t the ABA therapy is nt needed. If prir t discharge frm ne f these higher levels f care, if nging ABA therapy will be part f the patient s treatment plan a medical necessity review will need t be cmpleted using the guidelines belw fr utpatient applied behavir analysis therapy. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 16

17 Outpatient Applied Behavir Analysis Therapy Cverage fr applied behavir analysis may be subject t the fllwing: Care management requirements Subject t any deductibles, cpayments r cinsurance prvisins that apply t the medical r surgical services cvered under the plan. ABA therapy services are subject t prir apprval, hwever, prir apprval des nt guarantee cverage. Benefits are nt available fr the fllwing: Therapy duplicates services prvided by educatinal setting and/r is part f schlastic educatin Treatment is nt clinically apprpriate in terms f type, frequency, extent, site and duratin Treatment is primarily fr the cnvenience f the patient, physician, r ther health care prvider (ABA is therapy, nt babysitting) Member des nt have the diagnsis f Autism Spectrum Disrder (ASD) Required Elements fr ABA Therapy and All f the Fllwing Must be Met: Individual has a diagnsis f autism spectrum disrder (ASD) cnsistent with the DSM-5 criteria abve; and As determined by validated develpmental assessment tls, the individual cannt participate at an age apprpriate level in hme, schl r cmmunity activities, because f the presence f behaviral excess and/r the absence f functinal skills that interfere with participatin in these activities, and the targeted behavirs r skill deficits fr ABA meet either f the fllwing: The target behavir r skill deficit is ne standard deviatin r mre belw the mean (standard deviatin is a set value pint away frm the mean [average]. Standard deviatins are used t determine eligibility fr services, standard deviatins -1SD r -2SD wuld be 1 r 2 standards belw the mean [average]); r Represents a behavir that pses significant threat f harm t the individual r thers; and Any persn wh is prviding r supervising applied behavir analysis shall: Be licensed as a medical dctr, dctr f stepathy, r psychlgist in the state in which the applied behavir analysis services are being perfrmed; r Behavir Analyst Certificatin Bard, Inc (BACB) certified prviders (undergraduate-level certificatin in behavir analysis must be supervised by smene certified at the BCBA/BCBA-D level; may supervise RBT s, and thers wh implement behavir-analytic interventins); and Behaviral health treatment, cnsidered as evidence based interventins that will: Achieve specific imprvements in functinal capacity f a persn; and Are prvided by a licensed r certified practitiner as required abve; and Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 17

18 Treatment, cnsidered as evidence-based care is prescribed r rdered fr a persn diagnsed with an autism spectrum disrder by a licensed physician r psychlgist, including: Behaviral health treatment; Pharmacy care; and Therapeutic care; and If applicable the licensed r certified practitiner will crdinate treatment with the day care, preschl, schl, early interventin services prvider(s) and/r ther allied health services (i.e. ccupatinal therapy, speech therapy, physical therapy and any ther applicable prvider(s)) t reduce the likelihd f unnecessary duplicatin f services; and Parent(s) r caregiver(s) are available and cmmitted t full participatin in the prgram as prescribed, they must be invlved and engaged in the training and fllw thrugh n treatment recmmendatins beynd that prvided by licensed r certified practitiner(s) required abve; and After initial cmpletin f the assessment and develpment f the individualized treatment plan, the ABA therapy individualized treatment plan and prgress reprt dcuments will be cmpleted, updated and submitted every 6 mnths fr medical necessity review. The individualized treatment plan shuld be develped by a licensed prfessinal prvider e.g. medical dctr (M.D.), dctr f stepathy (D.O.), r psychlgist r by a BCBA r BCBA-D with a masters r dctral degree certified by the natinally accredited Behavir Analyst Certificatin Bard. Nte: After the initial authrizatin medical necessity review f the individual s prgress in meeting the bjectives f the treatment plan fr nging ABA therapy services shall be reviewed every six mnths unless it is determined that an earlier review is required, review requests fr the treatment f an individual receiving ABA therapy may be requested n mre than nce every 3 mnths. Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 18

19 Medical Necessity Review fr Initiatin f Applied Behavir Analysis (ABA) Therapy (Initial Assessment/Planning) : The initial review is t determine whether the individual meets eligibility criteria fr the ABA therapy (i.e. diagnsis, presence f autistic behavirs that are having clinically significant impact n functining in hme, schl, and/r cmmunity). If the individual meets the criteria i.e. the Required Elements abve, then the initial authrizatin will be fr 3 mnths fr the cmpletin f the assessment and develpment f an individualized treatment plan (ITP) including but nt limited t the infrmatin utlined belw. Fr cntinuatin f ABA therapy beynd this initial authrizatin please submit the assessment and individualized treatment plan t include the infrmatin utlined abve and see belw Medical Necessity Review fr Cntinuatin f ABA therapy. The Required Elements fr ABA Therapy are met abve; and A full assessment is planned t be cmpleted within the first 3 mnths where specific, measurable target behavirs are clearly and bjectively defined; and The assessment data is used t develp an individualized treatment plan as utlined abve and will include: Dates f service Identificatin and detailed descriptin f targeted symptms and behavirs that are preventing the individual frm adequately participating in age apprpriate hme, schl, r cmmunity activities, r that are presenting a safety risk t self, thers r prperty; Objective baseline measurements f each target symptm r behavir; Detailed descriptin f treatment mdality r mdalities and interventins fr each targeted symptm r behavir; Treatment gals and measures f prgress fr each targeted symptm and behavir, with estimated timeframes fr achieving the gals; If applicable the plan fr cmmunicatin and crdinatin with ther licensed r certified practitiner(s) r agencies including but nt limited t the fllwing: day care, preschl, schl, early interventin service prvider(s) and/r ther allied health services (i.e. ccupatinal therapy, speech therapy, physical therapy and any ther applicable prviders) t reduce the likelihd f unnecessary duplicatin f services Types f therapy prvided; Number f therapies per week; Behavirs/deficits targeted; Prgress related t treatment and services being prvided; and Measureable criteria fr cmpleting treatment with prjected plan fr cntinuatin f care after discharged frm ABA therapy; and Ttal number f days per week and hurs per day f direct services t patient and parent(s) r caregiver(s) t include duratin and lcatin f requested ABA therapy; and Licensure, certificatin, credentials f the prfessinal prviding services t the individual thrugh ABA therapy prgram; and Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 19

20 Nte: Parent(s) and/r caregiver(s) are available and cmmitted t full participatin in the prgram as prescribed, they are engaged in the training and fllw thrugh n treatment recmmendatins required beynd that prvided by the licensed r certified practitiner(s) required abve. The initial authrizatin t cmplete the assessment and individualized treatment plan is specific t applied behavir analysis and is nt inclusive f ther services being prvided (i.e. ccupatinal therapy, speech therapy, physical therapy, educatinal services (day care, preschl, schl, early interventin services), etc.). Dcumentatin f nsite supervisin f the applied behavir analysis must be prvided ABA therapy services are subject t prir apprval, hwever, prir apprval des nt guarantee cverage. Medical Necessity Review fr Cntinuatin f Applied Behavir Analysis (ABA) Therapy: After the initial authrizatin fr the assessment and individualized treatment plan (ITP) t be cmpleted, this infrmatin will be reviewed t determine medical necessity f any nging ABA therapy service(s). With each medical necessity review fr nging ABA therapy services an updated treatment plan and prgress reprt(s) will be required fr review, t include but nt limited t the infrmatin utlined belw. The fllwing will be required t be met in rder t substantiate the medical necessity fr the cntinuatin f the ABA therapy: The Required Elements fr ABA Therapy are met abve; and There is expectatin n the part f the treating prvider that the individual s behavir and skill deficits will imprve t a clinically meaningful extent, in at least tw settings (hme, schl, cmmunity) with ABA services; and The therapy is nt making the skill deficits and/r behavirs persistently wrse: and The individualized treatment plan and prgress reprt(s) submitted and were updated and prgress tward gals has been identified. Infrmatin prvided shuld include but is nt limited t the fllwing: Prgress is assessed and dcumented fr each targeted symptm and behavir, including prgress twards defined gals, and including the same mdes f measurement that were utilized fr baseline measurements f specific symptms and behavirs. The treatment plan and prgress reprt shuld reflect the fllwing: The individual shws imprvement frm baseline in skill deficits and prblematic behavirs targeted in the apprved treatment plan using validated assessments f adaptive functining. As determined by validated develpmental assessment tls, the individual still cannt participate at an age apprpriate level in hme, schl r Wellmark Blue Crss and Blue Shield is an independent licensee f the Blue Crss and Blue Shield Assciatin. 20