Clinical Policy Title: Applied behavior analysis

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1 Clinical Policy Title: Applied behavior analysis Clinical Policy Number: Effective Date: October 1, 2015 Initial Review Date: May 15, 2015 Most Recent Review Date: May 1, 2018 Next Review Date: May 2019 Policy contains: Applied behavior analysis. Early intensive behavioral intervention. Autism spectrum disorder. Related policies: CP# CP# Genetic testing for autism spectrum disorder Brain magnetic resonance imaging for autism ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas clinical policies are not guarantees of payment. Coverage policy AmeriHealth Caritas considers applied behavior analysis to be clinically proven and, therefore, medically necessary when all of the following criteria are met (Behavior Analyst Certification Board [BACB], 2014; InterQual, 2015)) Member eligibility criteria: - Diagnosis of autism, or autism spectrum disorder documented through a structured assessment and direct behavioral observation. - At least 18 months of age. - Treatment is initiated prior to age eight years. - Communication and social interaction deficits are exhibited in at least two different settings. - Presence of repetitive or restricted behaviors. - Intellectual functioning (one of the following): No suspicion of severe or profound intellectual disability. 1

2 Estimated intelligence quotient (IQ) at least Members under age 21 years who do not meet the above criteria require secondary review for medical necessity. Provider requirements (all criteria must be met): - Member is supervised directly or indirectly by either: A state-licensed physician or psychologist who provides a treatment plan for autism. Board-certified behavior analyst with graduate-level certification in behavior analysis (BCBA ) or doctoral training in behavior analysis [BCBA D ]. Board Certified Assistant Behavior Analyst (BCaBA ). - All direct treatment providers are credentialed for independent practice of applied behavior analysis, either: Certified by the Behavioral Analyst Certification Board. Licensed to provide applied behavior analysis by state statute. Treatment criteria (all criteria must be met): - A treatment plan must be submitted and followed with renewal every six months. - The treatment plan must focus on behavioral goals. - Therapeutic intensity must be age-appropriate and individualized: For children younger than age three years 25 to 30 hours per week. (Note: There are insufficient evidence-based studies on the use of applied behavior analysis for children younger than 36 months of age). For children older than age three years 30 to 40 hours per week. No additional benefit or coverage for more than 40 hours per week. - Treatment plan sets behavioral goals, and addresses and records progress in: Communications. Social and family interaction. Harmful behaviors. Continued treatment requires: o Measurement of progress using recognized instruments. o Continued progress toward goals. o Provider submitting documentation of progress on request. Limitations: Treatment services are limited to: Continuation up to 36 months after initiation of treatment. Treatment in excess of 36 months requires medical necessity review. The number of hours per week of parent training is determined collaboratively by the applied behavior analysis provider and supervisor, and the family. Up to three hours per week of caregiver training for school staff. No more than an average of two hours per week of consultation with other providers, 2

3 agencies, or school personnel. Therapy services such as occupational therapy, physical therapy, and speech therapy, when incorporated into the applied behavior analysis treatment plans, must have documentation of medical necessity and be included in plan benefits. Applied behavior analysis is not clinically proven and not medically necessary for adults ages 21 and over, or for individuals with other behavioral health disorders. Applied behavior analysis is not a plan benefit when used for educational achievement. All other uses of applied behavior analysis and early intensive behavioral intervention are not medically necessary. Alternative covered services: Alternative treatment includes medication, family counseling, standard behavioral health visits, and medically necessary institutional care. Background Autism is a neurodevelopmental disorder marked by impaired social communication and social interaction accompanied by atypical patterns of behavior and interest. Autism is a prevalent diagnosis occurring in one in 68 school-age children (CDC, 2017). The rising prevalence of autism increases the need for evidence-based behavioral treatments to lessen the impact of symptoms on children's functioning. At present, there are no curative or psychopharmacological therapies to effectively treat all symptoms of the disorder. Impairment due to autism is documented through structured assessment that demonstrates limitations in the child s ability to perform functional activities of daily living or participate in public school-based educational systems. All children must have baseline structured assessments (e.g., the Autism Diagnostic Observation Schedule or Screening Tool for Autism in Toddlers and Young Children) with follow-up assessments completed for concurrent review. The treatment plan must include goals specific to observed behaviors. The following information is required for all initial and concurrent reviews, and must be related to the individual needs of the member: Selection of interfering behavior or behavioral skill deficit. Identification of goals and objectives. Establishment of a method of measuring target behaviors. Evaluation of the current levels of performance (baseline). Design and implementation of the interventions that teach new skills and/or reduce interfering behaviors. 3

4 Continuous measurement of target behaviors to determine the effectiveness of the intervention. Ongoing evaluation of the effectiveness of the intervention, with modifications made as necessary to maintain and/or increase the effectiveness and the efficiency of the intervention. Applied behavior analysis: Applied behavior analysis is the systematic design, implementation, and evaluation of environmental modifications to produce socially significant improvement in human behavior (BACB, 2017). Applied behavior analysis involves discrete-trial teaching, breaking skills down into their most basic components, rewarding the demonstration of appropriate behavior with praise and positive reinforcement, and then "generalizing" skills in a naturalistic setting (LeBlanc, 2012). Generalization to the setting where behaviors naturally occur is an essential component of applied behavior analysis. Applied behavior analysis interventions for autism are based on the assumption that autism is a learning difficulty that can be addressed with operant conditioning strategies, such as systematically reinforcing target behaviors and teaching children to distinguish between different cues (Smith, 2010). Applied behavior analysis emphasizes both objective evaluation of the relationship of the environment to the individual s behavior, reliable functional assessment of undesirable behaviors, and treatment outcomes that are socially relevant and meaningful for the child (Center for Autism and Related Disorders, 2017). Family members and other care givers are essential to promote and maintain improvements in behavior and be involved in all treatment plan decisions. Early intensive behavioral intervention is a highly structured teaching approach for young children with autism (usually less than five years old) that is rooted in principles of applied behavior analysis based on the work of Lovaas (2016). The core elements of early intensive behavioral intervention involve: (a) a specific teaching procedure referred to as discrete trial training; (b) the use of a 1:1 adult-to-child ratio in the early stages of the treatment; and (c) implementation in either home or school settings for a range of 20 to 40 hours per week across one to four years of the child's life. Some guidelines on applied behavior analysis for autism are part of broader guidelines. Others specifically focus on applied behavior analysis treatment for the disorder. The Behavior Analyst Certification Board guideline addresses the training and credentialing of behavior analysts; assessment, creating treatment goals, and measuring client progress; service delivery models; training and licensing of behavior technicians; working with other professionals; and continuity of care (BACB, 2014). Searches AmeriHealth Caritas searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. 4

5 Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on April 2, Search terms were: applied behavior analysis, autism spectrum disorders, and early intensive behavioral intervention. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings A number of systematic reviews have been conducted to assess the ability of applied behavior analysis to improve health status for children with autism. One of the first systematic reviews (11 studies) found early intensive behavioral interventions resulted in significantly higher IQs and Vineland Adaptive Behavior Scale scores in children with autism (Howlin, 2009). A 2012 overview of five meta-analyses found that four of them concluded early intensive behavioral intervention for young children with autism effectively improved health status (Reichow, 2012b). Several reviews conclude that applied behavior analysis did not result in positive outcomes for children with autism. These include: 1. In a 34-study systematic review, only one was judged as good quality. While some clinically significant gains in language and cognitive skills were observed after early intensive behavioral and developmental interventions to young autistic children, authors raised cautions about making conclusions due to sub-standard data quality (Warren, 2011). 2. A Cochrane review of five trials (n=203) showed some evidence that early intensive behavioral interventions effectively improves behavior in some children with autism, but all but one of the trials were not randomized, and thus the evidence was seen as limited (Reichow, 2012a). 3. A review of 52 papers concluded that applied behavior analysis interventions are controversial, expensive, and dependent on external variables (Fernandes, 2013). 4. A systematic review and meta-analysis of 13 studies (six randomized trials) concluded that applied behavior analysis programs for preschool children with autism did not have better outcomes in cognitive functions like expressive language, receptive language, or adaptive 5

6 behavior (Spreckley, 2009). A systematic review of 48 randomized trials and 17 nonrandomized comparative studies found a low overall quality, but suggested behavioral interventions are associated with positive outcomes for some children with autism. Substantial advances are needed to enhance understanding of which interventions are most effective for specific children with autism (Weitlauf, 2014). A review of six randomized controlled trials resulted in a recommendation supporting initiation of interventions as soon as an autism diagnosis is seriously considered or determined; interventions begun before age three may have a greater positive impact than before age five. Families and/or caregivers should be actively involved in the treatment (Zwaigenbaum, 2015). In 2015, researchers from the University of Rochester Medical Center summarized the evidence base for treating children with autism under age five. The review categorized types of treatments into the probability of success, namely: 1. Well Established: 1) individual, comprehensive, and teacher-implemented applied behavior analysis; and 2) developmental and social-pragmatic (focused) applied behavior analysis. 2. Probably efficacious: 1) individual, focused applied behavior analysis for augmentative and alternative communication; 2) individual/focused applied behavior analysis and developmental social-pragmatic; and 3) focused developmental social-pragmatic training (Smith, 2015). The following year, a team from Ohio State University searched the medical literature and declared the most promising therapies recommended for autism care, in addition to healthy lifestyles, to be applied behavior analysis, parent-implemented training, melatonin supplements to improve sleep, supplements to correct deficiencies, and music therapy (Klein, 2016). Not all professionals have positive attitudes towards and knowledge of applied behavior analysis, but increased training can improve these attitudes and improve outcomes to children with autism. Teachers and classroom assistants in two schools for children with severe learning difficulties (including those with autism) reported a higher opinion of applied behavior analysis after completing a 90 minute training module (Smyth, 2017). The ability of applied behavior analysis principles given via telehealth to parents of 107 children with autism or other developmental disability was made. Average reduction in problem behavior after treatment for the in-home, clinic-based telehealth, and home-based telehealth training groups were 95.1, 91.0, and 97.3 percent, and treatment acceptability was high for each group. Costs of telehealth interventions were less than one-half that of in-home therapy (Lindgren, 2016). Policy updates: In April, 2018, a total of one guideline/other, five peer-reviewed references, and two InterQual sources were added to the policy. One guideline/other and two peer-reviewed references were removed. 6

7 Summary of clinical evidence: Citation Weitlauf (2014) for AHRQ Behavioral interventions for children (0 12 years) with ASD Reichow (2012a) Cochrane review EIBI for children with ASD Spreckley (2009) Applied behavior analysis in preschool children with ASD Howlin (2009) Content, Methods, Recommendations Key points: Systematic review of 48 randomized trials and 17 nonrandomized comparative studies (19 good, 39 fair, and seven poor quality) with at least 10 subjects per group. Overall quality: low. A growing evidence base suggests behavioral interventions are associated with positive outcomes for some children with ASD. Need intervention studies across settings and continued improvements in methodologic rigor. Substantial scientific advances are needed to enhance understanding of which interventions are most effective for specific children with ASD and to isolate components of interventions most associated with effects. Key points: Systematic review and meta-analysis of one randomized control trial (RCT) and four non-rcts (203 total patients). Overall quality: low due to high risk of bias among trials. Compared to treatment-as-usual comparison group, positive effects favoring the EIBI treatment group were found for all outcomes: adaptive behavior, IQ, expressive language, receptive language, daily communication skills, socialization and daily living skills. Additional studies using RCT research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD. Key points: Meta-analysis of 13 studies, six were RCTs. Applied behavior analysis programs did not significantly improve the cognitive outcomes of children in the experimental group who scored a standardized mean difference (SMD) of 0.38 (95 percent confidence interval [CI] to 0.84; P =.1). There was no additional benefit over standard care for expressive language; SMD of 0.37 (95 percent CI to 0.84; P =.11). Results for receptive language: SMD of 0.29 (95 percent CI to 0.74; P =.22) or adaptive behavior: SMD of 0.30 (95 percent CI to 0.77; P =.20). Key points: EIBI for children with ASD Systematic review of 11 studies, including two RCTs. At the group level, EIBI resulted in improved outcomes (primarily measured by IQ) compared to comparison groups. At an individual level, however, there was considerable variability in outcomes, with some evidence that initial IQ (but not age) was related to progress. There is some evidence for the effectiveness of EIBI for some, but not all, preschool children with autism. References 7

8 Professional society guidelines/other: Behavior Analyst Certification Board (BACB). Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers, 2 nd Edition. Littleton CO: BACB, Accessed April 3, Behavior Analyst Certification Board (BACB). About behavior analysis. Littleton CO: BACB, Accessed April 2, Center for Autism and Related Disorders (CARD). ABA Resources: What is ABA? CARD website. Accessed April 2, Lovaas Institute. Applied Behavior Analysis. Cherry Hill NJ: Lovaas Institute, Accessed April 2, National Autism Center The National Standards Project. Addressing the Need for Evidence-based Practice Guidelines for Autism Spectrum Disorders. Accessed April 2, Smith T. Early and intensive behavioral intervention in autism. In: Weisz J, Kazdin, AE, ed. Evidencebased psychotherapies for children and adolescents. 2nd ed., pp New York, NY: Guilford; U.S. Centers for Disease Control and Prevention (CDC). Autism Spectrum Disorder (ASD). Atlanta GA: CDC, last updated December 6, Accessed April 2, Volkmar F, Siegel M, Woodbury-Smith M, King B, McCracken J, State M. American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. February 2014; 53(2): Weitlauf AS MM, Peters B, Sathe N, et al. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative Effectiveness Review No (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No I.). AHRQ Publication No. 14-EHC036-EF. Rockville, MD: Agency for Healthcare Research and Quality; August Accessed April 2, 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. 2015; 136 Suppl 1: S Peer-reviewed references: 8

9 Fernandes FD, Amato CA. Applied behavior analysis and autism spectrum disorders: literature review. Codas. 2013;25(3): Howlin P, Magiati I, Charman T. Systematic review of early intensive behavioral interventions for children with autism. Am J Intellect Dev Disabil. 2009; 114(1): Klein N, Kemper KJ. Integrative approaches to caring for children with autism. Curr Probl Pediatr Adolesc Health Care. 2016;46(6): Leblanc LA, Heinicke MR, Baker JC. Expanding the consumer base for behavior-analytic services: meeting the needs of consumers in the 21st century. Behav Anal Pract. 2012; 5(1): Lindgren S, Wacker D, Suess A, et al. Telehealth and Autism: Treating Challenging Behavior at Lower Cost. Pediatrics. 2016;137 Suppl 2:S Reichow B. Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. J Autism Dev Disord. 2012a;42(4): 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. 2012b; 10: Cd Smith T, Iadarola S. Evidence Base Update for Autism Spectrum Disorder. J Clin Child Adolesc Psychol. 2015; 44(6): Smyth S, Reading BE, McDowell C. The impact of staff training on special educational needs professionals attitutes toward and understanding of applied behavior analysis. J Intellect Disabil. 2017: Doi: / Spreckley M, Boyd R. Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: a systematic review and meta-analysis. J Pediatr. 2009; 154(3): Warren Z, McPheeters ML, Sathe N, et al. A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics. 2011; 127(5): e CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Young J, Corea C, Kimani J, Mandell D. For CMS Center for Medicaid & State Operations. Disabled & Elderly Health Programs Group. Autism Spectrum Disorders (ASDs) Services. Final Report on 9

10 Environmental Scan. March 9, Accessed April 2, Autism Spectrum Disorders (ASD): State of the States of Services and Supports for People with ASD. HHSM I/HHSM-500-T0002. January 24, Accessed April 2, CMCS Informational Bulletin. Clarification of Medicaid Coverage of Services to Children with Autism. July 7, Accessed April 2, Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. InterQual : 2015 Residential & Community-based treatment criteria. Behavior modification B-MOD concurrent (custom) ACH Residential & Community-based treatment criteria. Behavior modification B-MOD initial (custom) ACH. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill in accordance with those manuals. CPT Code Description Comment 0359T Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report 0360T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient +0361T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient 0362T Exposure behavioral follow-up assessment, includes physician or other qualified health 10

11 CPT Code Description Comment care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient +0363T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient ICD-10 Code Description Comment F84.0 Autistic disorder F84.2 Rett s syndrome F84.3 Other childhood disintegrative disorder F84.5 Asperger s syndrome F84.8 Other pervasive developmental disorder F84.9 Atypical autism HCPCS Level II Code N/A Description Comment 11