Clinical Policy Title: Applied behavior analysis (ABA)

Transcription

1 Clinical Policy Title: Applied behavior analysis (ABA) Clinical Policy Number: Effective Date: October 1, 2015 Initial Review Date: May 15, 2015 Most Recent Review Date: June 15, 2016 Next Review Date: June 2017 Related policies: Policy contains: Applied behavior analysis. Early intensive behavioral intervention. Early Start Denver Model. Autism spectrum disorder. CP# Genetic testing for autism spectrum disorder ABOUT THIS POLICY: Keystone First has developed clinical policies to assist with making coverage determinations. Keystone First s 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 Keystone First 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. Keystone First s 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. Keystone First s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Keystone First will update its clinical policies as necessary. Keystone First s clinical policies are not guarantees of payment. Coverage policy Keystone First considers applied behavior analysis (ABA) to be clinically proven and, therefore, medically necessary when the following criteria are met: A. Eligibility criteria Child carries diagnosis of autism spectrum disorder (ASD) documented through a structured assessment. Treatment initiated prior to age 8 years. Continued treatment requires reassessment every six months. Continued treatment up to 36 months after initiation of treatment. Individuals outside the above criteria will be evaluated case by case based on evidence of medical necessity. 1

2 B. Provider requirements Provider holds a doctoral degree in clinical psychology, counseling psychology, school psychology or another applied health service area of psychology. Provider has at least two years of experience in a supervised health service setting in which one year of experience was obtained in an organized health service training program and at least one year of experience was obtained after the individual received his or her doctoral degree in psychology. Provider complies with continuing education requirements of the state in which the provider is licensed. If available within state-based access standards, the provider must be certified by the Behavioral Analyst Certification Board (BACB). C. Treatment criteria A treatment plan must be submitted and followed with renewal every six months. The treatment plan must focus on behavioral goals. Therapeutic intervention duration must be age-appropriate and individualized: For children younger than age 3 years, 25 to 30 hours per week. For children older than age 3 years, 30 to 40 hours per week. No additional benefit or coverage for more than 40 hours per week. Note: There are insufficient evidence-based studies on the use of ABA for children younger than 36 months of age. Treatment plan sets behavioral goals, and addresses and records progress in: Communications. Social and family interaction. Harmful behaviors. Continued treatment must include: Measurement of progress using recognized instruments. Continued progress toward goals. Provider submitting documentation of progress on request. Limitations: Therapy services such as occupational therapy, physical therapy and speech therapy, when incorporated into the ABA treatment plans, must have documentation of medical necessity and be included in plan benefits. ABA may be reviewed case by case for evidence of medical necessity in children under age 21 years who do not meet the criteria in this coverage policy. ABA is not clinically proven and not a plan benefit for adults ages 21 and over, or for individuals with other behavioral health disorders. ABA is not a plan benefit when used for educational achievement. All other uses of ABA and early intensive behavioral intervention (EIBI) are not medically necessary. Alternative covered services: 2

3 Alternative treatment includes medication, family counseling, standard behavioral health visits and medically necessary institutional care. Background ASD is a prevalent diagnosis occurring in one in 68 school-age children (Centers for Disease Control and Prevention [CDC], 2016). The rising prevalence of ASD 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. ABA is the systematic design, implementation and evaluation of environmental modifications to produce socially significant improvement in human behavior (BACB, 2016). ABA 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 ABA. ABA interventions for ASD are based on the assumption that ASD 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). EIBI is a highly structured teaching approach for young children with ASD (usually less than 5 years old) that is rooted in principles of ABA based on the work of Lovaas (2016). The core elements of EIBI 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. Assessment: Impairment due to ASD must be 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 [ADOS] or Screening Tool for Autism in Toddlers and Young Children) with follow-up assessments completed for concurrent review. 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. Treatment options and methods: ABA treatment has important characteristics that should be apparent throughout treatment: An objective analysis of the individual s condition by observing the relationship of the environment to the individual s behavior, as reflected through detailed data collection. An understanding of the context of the behavior and its value to the individual and the environment. Applications of the principles and procedures of behavior analysis in concert with the health and well-being of the individual. Treatment outcomes that are socially relevant and meaningful for the child. Treatment plan expectations (include parents role as well as what should be included and how it is used): Strengths-based. Family-centered. Goals are SMART (strengthening mental abilities with relational training) that include caregiver training and transfer of skills. A focus on problems in the following areas: Cognitive functioning. Pre-academic skills. Safety skills. Social skills. Play and leisure skills for community integration. Vocational skills. Coping and tolerance skills. Adaptive and self-help skills. Language and communication. Attending and social referencing. Reduction of interfering and inappropriate behaviors. Treatment protocols: The following characteristics should be evident in all phases of assessment, diagnosis and treatment: Specific levels of baseline behavior defined when developing treatment goals. 4

5 Treatment directed at establishing small units or behavior targets, which build up to larger and more significant changes in functioning. Detailed data collection on behavioral targets to measure progress toward treatment goals. It must be measurable and obtained from direct observational data analysis. Functional behavior assessment (FBA). There must be an understanding of the function of the behaviors being treated. A functional assessment of undesirable behaviors is critical because most problem behaviors serve a purpose and are reinforced by their consequences. Examples are to gain attention, avoid an undesirable request or situation, and engage in a particular activity or reach a particular objective. Behavior intervention plan (BIP) using information gathered from the FBA. The BIP outlines a plan for decreasing the frequency of the behavior. Treatment environment(s) maintained to minimize problematic behaviors. A carefully designed, individualized and detailed behavior analytic treatment that uses evidence-based behavior analytic treatment methods. Frequent direct assessment, analysis and adjustments to the treatment plan based on the individual s progress based on observable and measurable data analysis. Treatment protocols implemented frequently in various environments until the individual can function in a variety of situations. Family members, a key component of the program, provided support and training to promote and maintain improvements in behavior. They should be involved in all decisions on programming for the child. Supervision by a board-certified behavior analyst or licensed behavioral health clinician who ensures that strategies are appropriately implemented. This is especially important for parents with newly diagnosed children. Sustainability of treatment approach: Queues for parents to know when to access follow-up help. Boosters. Searches Keystone First searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. 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 May 12, Search terms were: applied behavior analysis, autism spectrum disorders and early intensive behavioral intervention. We included: 5

6 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 ABA, EIBI and similar behavioral techniques have a low-to-moderate level of evidence to demonstrate effectiveness in young children. Studies interventions were conducted primarily in preschool-age and early school-age children (i.e., typically children initially ages years). The cognitive, language and adaptive behavior profiles of participants included in these studies were generally in line with those seen in the community. The evidence suggests that early behavioral and developmental intervention based on the principles of ABA delivered in an intensive (> 15 hours per week) and comprehensive (i.e., addressing numerous areas of functioning) approach can positively affect a subset of children with ASD. Across approaches, children receiving early intensive behavioral and developmental interventions demonstrate improvements in cognitive, language, adaptive and ASD impairments compared with children receiving low-intensity interventions and eclectic non-aba-based intervention approaches. Although the quality of clinical evidence is moderate to low, ABA or behavioral treatment is the only well-established and efficacious treatment for children diagnosed with ASDs according to the Chambliss Criteria used to evaluate the degree of published empirical support for psychosocial interventions. Studies have failed to show the effectiveness of ABA for older children or adults, or for continuation of this therapy for more than three years. EIBI is an expensive treatment when delivered at the level that achieves optimal results, although savings will likely be obtained in the future through the avoidance of higher levels of care and/or custodial services for older children, adolescents and adults. Thus, a long-term view of overall health and functional ability requires consideration of this approach for appropriate candidates. Policy updates: We added one systematic review from the Agency for Healthcare Quality and Research (AHRQ) (Weitlauf, 2014). This systematic review identified a growing evidence base with some improvement in study quality. However, significant limitations in research remain. Their results support findings of 6

7 earlier reviews. These results would not change earlier conclusions and warrant no changes to the policy. Summary of clinical evidence: Citation Weitlauf (2014) for AHRQ Behavioral interventions for children (0 12 years) with ASD Reichow (2012) Content, methods, recommendations Key points: Systematic review of 48 randomized trials and 17 nonrandomized comparative studies (19 good, 39 fair and 7 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 studies of interventions 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: Cochrane review EIBI for children with ASD 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. Spreckley (2009) ABA in preschool children with ASD Key points: Meta-analysis of 13 studies, six were RCTs. ABA 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). 7

8 Citation Howlin (2009) Content, methods, recommendations 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. Glossary Applied behavioral analysis (ABA) A systematic approach for influencing socially important behavior through the identification of reliably related environmental variables and the production of behavior change techniques that make use of those findings. Autism spectrum disorder (ASD) A neurodevelopmental disorder marked by impaired social communication and social interaction accompanied by atypical patterns of behavior and interest. Early intensive behavioral intervention (EIBI) A specific type of ABA for very young children (often age 5 or younger) with an ASD. Services involve discrete-trial teaching, breaking skills down into their most basic components and rewarding positive performance, and are provided on a one-to-one basis in a manner individualized to meet each child s developmental needs. Individuals with Disabilities Education Act Federal legislation providing students with disabilities access that is tailored to individual needs with a free appropriate public education. References Professional society guidelines/other: About behavior analysis. Behavior Analyst Certification Board website. Accessed May 12, CDC. Autism Spectrum Disorder (ASD). CDC website. Accessed May 12, Filipek PA, Accardo PJ, Ashwal S, et al. 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):

9 Lovaas Institute Homepage. Lovaas Institute website. Accessed May 16, National Autism Center The National Standards Project. Addressing the Need for Evidence-based Practice Guidelines for Autism Spectrum Disorders. Accessed May 16, 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): 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: 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): e Dorsey MF, Weinberg M, Zane T, Guidi MM. The case for licensure of applied behavior analysts. Behav Anal Pract. 2009; 2(1): 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): 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): 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. 2012; 10: Cd 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; Smith T, Iadarola S. Evidence Base Update for Autism Spectrum Disorder. J Clin Child Adolesc Psychol. 2015; 44(6):

10 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 Weitlauf AS MM, Peters B, Sathe N, Travis R, Aiello R, Williamson E, Veenstra-VanderWeele J, Krishnaswami S, Jerome R, Warren Z. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Comparative Effectiveness Review No (Prepared by the Vanderbilt Evidencebased Practice Center under Contract No I.). AHRQ Publication No. 14-EHC036-EF. Rockville, MD: Agency for Healthcare Research and Quality; August Accessed May 16, Clinical trials: Searched clinicaltrials.gov on May 16, 2016, using terms autism applied behavioral analysis OR early intervention behavioral analysis Open Studies. 13 studies found, three relevant. Sensory Integration Therapy in Autism: Mechanisms and Effectiveness. ClinicalTrials.gov website. Published August 27, Updated August 28, Accessed May 16, Feasibility Testing and Pilot Study of V-MOTIVE Protocol Software Version 1. ClinicalTrials.gov website. Published July 9, Updated July 14, Accessed May 16, Using Web-based Technology to Expand and Enhance Applied Behavioral Analysis Programs for Children With Autism in Military Families. ClinicalTrials.gov website. Published June 5, Updated June 14, Accessed May 16, (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 Environmental Scan. March 9, CMS website. Information/By-Topics/Long-Term-Services-and-Supports/Downloads/Autism-Spectrum-Disorders.pdf. Accessed May 16,

11 Autism Spectrum Disorders (ASD): State of the States of Services and Supports for People with ASD. HHSM I/HHSM-500-T0002. January 24, CMS website. Supports/Downloads/ASD-State-of-the-States-Report.pdf. Accessed May 16, Local Coverage Determinations (LCDs): No LCDs identified as of the writing of this policy. 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 0360T 0361T 0362T 0363T 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 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-toface with the patient 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 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; first 30 minutes of technician(s) time, face-to-face with the patient 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 11

12 ICD-10 Code Description Comment F84.3 Other childhood disintegrative disorder F84.5 Asperger s syndrome F84.8 Other pervasive developmental disorder F84.9 Atypical autism HCPCS Level II N/A Description Comment 12