Policy. Medical Policy Manual Approved: Do Not Implement Until 1/1/18. Applied Behavioral Analysis (ABA)

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1 Plicy Medical Plicy Manual Apprved: D Nt Implement Until 1/1/18 Applied Behaviral Analysis (ABA) This medical plicy will apply t self-funded grups upn their renewal, beginning 1/1/18. Des nt apply t BlueCare. DESCRIPTION Applied behaviral analysis (ABA) therapy is a structured and systematic apprach t reduce the intensity, frequency and/r duratin f challenging behavirs and increase the use f critical adaptive behavirs fr thse individuals wh have a diagnsis f Autism Spectrum Disrder (ASD). Challenging behavirs include, but are nt limited t aggressin, vilence, destructiveness, self-injury (scratching, biting, head-banging), and selfstimulatry behavir which is repetitive and ritualistic (rcking, pacing, jumping up and dwn, gazing, lining up bjects). Critical adaptive behavirs include, but may nt be limited t rudimentary cmmunicatin skills, eating and tilet training. Autism spectrum disrder (ASD) is a neurdevelpmental disrder marked by impaired scial cmmunicatin and scial interactin accmpanied by atypical patterns f behavir and interest. ASD is differentiated frm ther develpmental disrders by significant impairments in scial interactin and cmmunicatin, alng with restrictive, repetitive, and steretypical behavirs and activities. The cnditins frmerly called autism, Asperger syndrme, and pervasive develpmental delay nt therwise specified were merged int a single diagnsis called ASD in ABA therapy invlves a systematic analysis f behavir by a qualified practitiner, utilizing careful bservatin in the child s natural envirnment t identify challenging behavirs that are triggered by envirnmental factrs. A treatment plan is develped and implemented that uses envirnmental mdificatin, behaviral stimuli and cnsequences t prduce scially significant imprvements in critical adaptive behavirs and reduce the severity and frequency f challenging behavirs. Parental/caregiver invlvement is essential t lng-term treatment success. ABA therapy prgrams may als be referred t as intensive behaviral interventin (IBI), early intensive behaviral interventin (EIBI), Lvaas therapy [als referred t as the University f Califrnia Ls Angeles (UCLA) methd], r Early Start Denver Mdel (ESDM). Prviders must use the fllwing frms: Applied Behaviral Analysis (ABA) Therapy Evaluatin fr Services Request Frm Applied Behaviral Analysis (ABA) Therapy Initiatin r Cntinuatin f Services Request Frm POLICY Applied Behavir Analysis (ABA) therapy fr the treatment f Autism Spectrum Disrder may be cnsidered medically necessary if the medical apprpriateness criteria are met. (See Medical Apprpriateness belw) Applied Behaviral Analysis (ABA) therapy rendered in any f the fllwing frmats is cnsidered nt medically necessary: Grup therapy frmat Telemedicine frmat (in cmpliance with TN State law) Parent and/r caregiver supprt grups This dcument has been classified as public infrmatin.

2 Plicy Medical Plicy Manual Apprved: D Nt Implement Until 1/1/18 Applied Behaviral Analysis (ABA) therapy interventins that include, but are nt limited t, any f the fllwing wuld be cnsidered investigatinal: Academic Interventins Animal-assisted Therapy Auditry Integratin Training Cncept Mapping DIR/Flr Time Educatinal Services Facilitated Cmmunicatin Fd Preparatin Skills Mvement-based Interventin Respite Care SENSE Theatre Interventin Sensry Interventin Package Shck Therapy Scial Behaviral Learning Strategy Scial Cgnitin Interventin Scial Thinking Interventin Technlgy-based Treatment Thery f Mind Training Vcatinal Rehabilitatin Applied Behaviral Analysis therapy fr the treatment f all ther cnditins/diseases is cnsidered investigatinal. See als: Sensry and Auditry Integratin Therapies Speech / Language Therapy, Occupatinal Therapy and Physical Therapy fr Autism Spectrum Disrder MEDICAL APPROPRIATENESS Applied Behavir Analysis (ABA) therapy fr the treatment f Autism Spectrum Disrder may be cnsidered medically apprpriate when ANY ONE f the fllwing are met: Evaluatin fr Applied Behaviral Analysis (ABA) therapy services if ALL f the fllwing are met: Diagnsis f Autism Spectrum Disrder using ne r mre validated assessment tls [e.g. DSM-5 severity levels rating, Autism Diagnstic Observatin Schedule (ADOS), Autism Diagnstic Interview (ADI-R), Childhd Autism Rating Scale (CARS), Gilliam Autism Rating Scale (GARS)] There are symptms r behavirs that are preventing the individual frm adequately participating in age apprpriate hme, schl r cmmunity activities There are symptms r behavirs that are presenting a safety risk t self, thers r prperty Severity assessment f autism symptms has been perfrmed within the last 6 mnths (e.g. CARS, DSM-5 severity levels rating, Scial Cmmunicatin Questinnaire) Evaluatin fr services will be dne n a 1:1 basis between the qualified practitiner and the individual member and/r caregiver Applied Behaviral Analysis (ABA) Therapy Evaluatin fr Services Request Frm cmpleted and submitted (Evaluatin perid nt t exceed 15 hurs; within 30 days) This dcument has been classified as public infrmatin.

3 Plicy Medical Plicy Manual Apprved: D Nt Implement Until 1/1/18 Initiatin f Applied Behaviral Analysis (ABA) therapy if ALL f the fllwing are met: Individual is nt in an inpatient, residential, r partial hspitalizatin setting Individual is nt receiving 24/7 nursing care Applied Behaviral Analysis (ABA) Therapy Evaluatin fr Services Request Frm has been apprved The ABA therapy is rendered n a 1:1 basis between the qualified practitiner and the individual member and/r caregiver Parent(s) and/r caregiver(s) are engaged and participate in ABA therapy Parent(s) and/r caregiver(s) agree t fllw apprpriate treatment plan recmmendatins Individual s ABA therapy treatment plan has been submitted (ABA therapy nt t exceed 20 hurs per mnth; additinal hurs may be cnsidered n a case by case basis fr members with significant needs) Cntinuatin f Applied Behaviral Analysis (ABA) therapy if ALL f the fllwing are met: Individual is nt in an inpatient, residential, r partial hspitalizatin setting Individual is nt receiving 24/7 nursing care The ABA therapy cntinues t be rendered n a 1:1 basis between the qualified practitiner and the individual member and/r caregiver Applied Behaviral Analysis (ABA) Therapy Initiatin r Cntinuatin f Services Request Frm has been cmpleted and submitted fr review (at least nce every 6 mnths) Parent(s) and/r caregiver(s) remain engaged and are participating in the ABA therapy Parent(s) and/r caregiver(s) are fllwing apprpriate treatment plan recmmendatins Individual s ABA therapy treatment plan (ABA therapy nt t exceed 20 hurs per mnth; additinal hurs may be cnsidered n a case by case basis fr members with significant needs) has been updated, submitted and demnstrates ALL f the fllwing: Prgress made tward gals Symptms/behavirs that present a safety risk t self, thers r prperty persist Symptms/behavirs that prevent the individual frm adequately participating in age apprpriate hme, schl r cmmunity activities persist Prgress tward gals cannt be maintained if care is reduced r discntinued APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS Tenn. Cde Ann (2016) Autism spectrum disrders. IMPORTANT REMINDERS Any specific prducts referenced in this plicy are just examples and are intended fr illustrative purpses nly. It is nt intended t be a recmmendatin f ne prduct ver anther, and is nt intended t represent a cmplete listing f all prducts available. These examples are cntained in the parenthetical e.g. statement. We develp Medical Plicies t prvide guidance t Members and Prviders. This Medical Plicy relates nly t the services r supplies described in it. The existence f a Medical Plicy is nt an authrizatin, certificatin, explanatin f benefits, r a cntract fr the service (r supply) that is referenced in the Medical Plicy. Fr a determinatin f the benefits that a Member is entitled t receive under his r her health plan, the Member's health plan must be reviewed. If there is a cnflict between the Medical Plicy and a health plan, the express terms f the health plan will gvern. This dcument has been classified as public infrmatin.

4 Plicy Medical Plicy Manual Apprved: D Nt Implement Until 1/1/18 ADDITIONAL INFORMATION Since the 1980 s a grwing evidence base suggests that behaviral interventins are assciated with psitive utcmes fr children with ASD. Hwever, it is generally agreed amng practitiners and majr prfessinal scieties that the evidence is at best lw quality with wide variatins in methdlgy, findings and philsphical bias making well defined cnclusins difficult. SOURCES Agency fr Healthcare Research and Quality. U. S. Department f Health and Human Services. (2014, August). Effective Health Care Prgram. Cmparative Effectiveness Review, Number 137. Therapies fr children with autism spectrum disrder: behaviral interventins update. Retrieved April 21, 2016 frm American Academy f Child and Adlescent Psychiatry. Cmmittee n Quality Issues. (2014, February). Practice parameter fr the assessment and treatment f children and adlescents with autism spectrum disrder. Jurnal f the American Academy f Child & Adlescent Psychiatry, 53 (2), American Academy f Child and Adlescent Psychiatry (AACAP) Cmmittee n Quality Issues (CQI). (February, 2014). Practice parameter fr the assessment and treatment f children and adlescents with autism spectrum disrder. Retrieved April 20, 2016 frm the Natinal Guideline Clearinghuse (NGC: ). American Academy f Pediatrics. (2012). Pediatrics. Nnmedical interventins fr children with ASD: recmmended guidelines and further research needs. Retrieved April 21, 2016 frm American Psychiatric Assciatin (2013, May). Diagnstic and statistical manual f mental disrders (DSM-5): autism spectrum disrder. Retrieved September 22, 2016 frm: Cincinnati Children s Hspital Medical Center. (June, 2012). Best evidence statement (BESt). The use f vide-based mdeling in teaching daily living skills t children with autism. Retrieved April 20, 2016 frm the Natinal Guideline Clearinghuse (NGC: 9273). Cincinnati Children s Hspital Medical Center. (February, 2013). Best evidence statement (BESt). Adding hme based services t cmplement center based interventin fr children with autism. Retrieved April 20, 2016 frm the Natinal Guideline Clearinghuse (NGC: 9777). Dawsn, G., Rgers, S., Munsn, J., Smith, M., Winter, J., Greensn, J., et al. (2010). Randmized cntrl trial f an interventin fr tddlers with autism: The early start Denver mdel. Pediatrics, 125 (1), e17- e23. (Level 3 evidence) Lvaas, O. I. (1993). The develpment f a treatment-research prject fr develpmentally disabled and autistic children. Jurnal f Applied Behavir Analysis, 26 (4), (Level 4 evidence) Natinal Academies Press (2001). Educating children with autism: adaptive behavirs. Chapter 9. Washingtn DC: The Natinal Academies f Sciences, Engineering, and Medicine. Natinal Autism Center (2009). Natinal standards prject: Phase 1. Addressing the needs fr evidence based practice guidelines fr autism spectrum disrder: findings and cnclusins. Retrieved September 22, 2016 frm: This dcument has been classified as public infrmatin.

5 Plicy Medical Plicy Manual Apprved: D Nt Implement Until 1/1/18 Natinal Autism Center (2015). Natinal standards prject: Phase 2. Addressing the needs fr evidence based practice guidelines fr autism spectrum disrder: findings and cnclusins. Retrieved September 22, 2016 frm: Ospina, M. B., Selda, J. K., Clark, B., Karkhaneh, M., Hartling, L., Tjsvld, L., et al. (2008). Behaviural and develpmental interventins fr autism spectrum disrder: A clinical systematic review. PLS One, 3 (11), 1-32.e3755. (Level 1 evidence) Reichw, B., & Wlery, M. (2009). Cmprehensive synthesis f early intensive behaviral interventins fr yung children with autism based n the UCLA yung autism prject mdel. Jurnal f Autism and Develpmental Disrders, 39 (1), (Level 1 evidence) Serna, R. W., Lb, H. E., Fleming, C. K., Fleming, R. K., Curtin, C., Fran, M. M., et al. (2015). Innvatins in behaviral interventin preparatin fr paraprfessinals wrking with children with autism spectrum disrder. Jurnal f Special Educatin Technlgy, 30 (1), (Level 5 evidence) Spreckley, M., & Byd, R. (2009). Efficacy f applied behaviral interventin in preschl children with autism fr imprving cgnitive, language, and adaptive behavir: A systematic review and meta-analysis. The Jurnal f Pediatrics, 154 (3), (Level 1 evidence) Technlgy Evaluatin Center. (2015, March). Special reprt: Early intensive behaviral interventin based n applied behavir analysis amng children with autism spectrum disrder. (Vl. 30, N. 1). Chicag: BlueCrss BlueShield Assciatin. (30 articles and/r guidelines reviewed) Tennessee Cde: Title 56 Insurance: Chapter 7 Plicies and Plicyhlders: Part 23 Mandated Insurer r Plan Optins: Autism spectrum disrders. Retrieved September 22, 2016, 2016 frm U. S. Preventative Services Task Frce ( 2016, February) Screening fr autism spectrum disrder in yung children. Retrieved September 22, 2016 frm: Natinal Guideline Clearinghuse (NGC#010905) Virues-Ortega, J. (2010). Applied behavir analytic interventin fr autism in early childhd: Meta-analysis, meta-regressin and dse respnse meta-analysis f multiple utcmes. Clinical Psychlgy Review (30) (Level 2 evidence) Winifred S. Hayes, Inc. Medical Technlgy Directry. (2014, December, last update search Nvember 2015). Applied behavir analysis-based interventins fr autism spectrum disrder. Retrieved April 20, 2016 frm (130 articles and/r guidelines reviewed) EFFECTIVE DATE 1/1/2018 ID_BT This dcument has been classified as public infrmatin.

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