MEDICAL POLICY Children's Intensive Behavioral Service/ Applied Behavioral Analysis (ABA)

Transcription

1 POLICY: PG0335 ORIGINAL EFFECTIVE: 12/17/15 LAST REVIEW: 07/10/18 MEDICAL POLICY Children's Intensive Behavioral Service/ Applied Behavioral Analysis (ABA) GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. DESCRIPTION Autism spectrum disorder (ASD) is a pervasive developmental neuropsychiatric disorder that manifests early in life (usually within the first few years). The condition is characterized by persistent impairments in social communication and interaction as well as restricted and repetitive interests, activities, or behavioral patterns. There is currently no cure for ASD, nor is there any single treatment for the disorder, although ASD may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions. The goal of treatment for children with ASD is to minimize the severity of autism symptoms, maximize learning, facilitate social integration, and improve quality of life for both autistic individuals and their families or caregivers. One type of behavioral therapy program uses operant conditioning techniques based on the principles of applied behavior analysis (ABA) to help individuals with ASD develop skills with social value. Overall, the evidence for ABA-based therapies for treatment of ASD is of low quality, with individual study quality ranging from poor to good. The quality of evidence varied considerably by outcome. There is moderate quality evidence that ABA-based therapies have a positive effect for the outcomes of intelligence/cognitive measures and language skills. Lowquality evidence indicates that ABA-based therapies have a positive effect on the outcome of adaptive behavior and school placement. The evidence would be considered of very low quality for autism severity and visualspatial/nonverbal skills. POLICY Children's Intensive Behavioral Service ( ) & Applied Behavior Analysis (0359T-0374T) are noncovered for Elite. Children's Intensive Behavioral Service ( ) & codes 0360T-0363T, 0366T, 0367T, 0370T-0374T are non-covered for Advantage. Effective 07/01/18 Applied Behavior Analysis (0359T, 0364T, 0365T, 0368T, & 0369T) requires prior authorization for Advantage. Children's Intensive Behavioral Service ( ) & Applied Behavior Analysis (0359T-0374T) requires prior authorization for HMO, PPO, & Individual Marketplace. Elite Children's Intensive Behavioral Service & Applied Behavioral Analysis (ABA) for the assessment and/or treatment of ASD is non-covered. Advantage Prior to 07/01/18, Paramount defers to the Ohio Department of Mental Health and Addiction Services providers for access, delivery and payment of these services for Advantage members. Effective 07/01/18, Paramount sets forth the qualifications for enrollment and reimbursement for a provider who provides treatment for recipients with a primary diagnosis of autism spectrum disorder (ASD). A. For the purposes of this rule the following definitions apply: 1. "Autism spectrum disorder" is defined as a diagnosis of one of the following: a. Autistic disorder b. Rett's syndrome c. Asperger's syndrome d. Pervasive developmental disorder, unspecified

2 e. Other pervasive developmental disorders f. Other childhood disintegrative disorder 2. "Confirmational diagnosis" is a diagnostic procedure for the presence of ASD performed subsequent to the initial diagnostic procedure. The confirmation diagnosis must be performed by a provider other than the one who may be rendering the ASD treatment services, and must make use of one or more of the following tools: a. Autism diagnostic observation schedule (ADOS) b. Autism diagnostic interview (ADI) c. Diagnostic interview for social and communication disorders (DISCO) 3. "Organizational provider" means a provider that provides services to recipients with a primary diagnosis of ASD and is recognized by the Ohio Department of Medicaid as a professional medical group. B. Eligible providers of services for recipients with a primary diagnosis of ASD shall be an organization that provides the services and meets all of the following requirements: 1. Holds an active accreditation by one or more of the following national accreditation organizations: a. The joint commission previously known as the joint commission on accreditation of healthcare organizations b. The commission on accreditation of rehabilitation facilities (CARF) c. The national committee on quality assurance (NCQA) d. The community health accreditation partner (CHAP) e. The council on accreditation (COA) 2. Employs or contracts with Ohio behavior analysts who have been certified (COBA) by the Ohio board of psychology and work within their scope of practice as defined by state law and at least one of these practitioner types: a. Speech-language practitioners who have been certified by the American speech-language-hearing association and have a valid license as a speech language pathologist and work within their scope of practice as defined by state law; and b. Audiology practitioners who have been certified by the American speech-language-hearing association and have a valid license as an audiologist and work within their scope of practice as defined by state law: and c. Occupational therapy practitioners who hold a valid license as an occupational therapist and work within their scope of practice as defined by state law; and d. Physical therapy practitioners who hold a valid license as a physical therapist and work within their scope of practice as defined by state law; and e. Ohio behavior analysts who have been certified (COBA) by the Ohio board of psychology and work within their scope of practice as defined by state law. 3. Practitioners eligible to secure a provider agreement with Paramount must do so and affiliate with the ASD provider(s) with which they are employed or hold an employment contract. 4. Provide services to children or adults with a primary diagnosis of ASD that, at a minimum, include behavior therapy including a behavior health assessment, that is provided by or delivery is supervised by a COBA, or practitioner operating within their scope of practice, and at least one of the categories of coverage: a. Speech-language pathology therapy services b. Audiology services c. Physical therapy services d. Occupational therapy services e. Behavior therapy, including a behavior health assessment, that is provided by or delivery is supervised by a COBA, or practitioner operating within their scope of practice. C. Coverage and limitations: 1. Additional medically necessary physical, occupational, and speech therapy and audiology services beyond the treatment limitations may be rendered by an ASD provider when prior approved by Paramount. 2. Behavior therapy service limitations include: a. Prior authorization, by the Paramount designated entity. b. The development of a behavior assessment before services are provided. The assessment requires a physician's order, and shall include the development of a treatment plan detailing services to be rendered to the recipient. A total of two assessments may be performed during a twelve month period. c. The development of a documented time-limited, individualized treatment plan should include ALL of the following: Includes identifiable maladaptive target behaviors having a negative impact on development, communication, social interactions, safety, environment or function

3 There is a time-limited individualized treatment plan developed Defines objective baseline measures including frequency, rate, intensity and duration Establishes specific and quantifiable criteria for progress Demonstrates that ABA therapy is not custodial or maintenance-oriented in nature and is planned to prevent, diagnose, evaluate, correct, ameliorate, or treat the ASD Is completed by the treating provider and includes coordination across all providers, supports and resources Includes services that are not recreational in nature, or for the purposes of respite or residential care Identifies parental or guardian involvement in prioritizing target behaviors, and training in behavioral techniques in order to provide additional and supportive interventions Includes criteria and specific behavioral goals and interventions for lesser intensity of care and discharge There is evidence of identified and involved community resources d. Ongoing review of progress, the frequency of which is determined by clinical review and/or applicable state laws, must be developed and documented by a licensed practitioner as defined in this policy and include ALL criteria above, as well as: Upon request, a letter indicating the continued medical necessity from a licensed credentialed psychologist, psychiatrist, or developmental pediatrician that includes consideration of less intensive interventions and rationale for continued ABA therapy An updated individualized treatment plan noting specific measurable progress on targeted behaviors identified in initial treatment plan (e.g. frequency, rate, intensity and duration), and new or refined interventions evidencing individualized need and demonstrating the non-custodial nature of care. Updated criteria and specific behavioral goals and interventions for lesser intensity of care and discharge must be included; as well as documentation of updated parental or guardian involvement in prioritizing target behaviors and training in behavioral techniques in order to provide additional and supportive interventions e. Service provision limits and prior authorizations required are not specific to the location of service provision, but rather shall apply to the entire treatment program of the recipient receiving services. 3. Services provided by an eligible ASD provider or by hospital outpatient departments are reimbursable. 4. A confirmational diagnosis may be required as a component of the prior authorization process. 5. Nothing in this rule shall preclude Paramount from contracting with a provider that has not achieved the accreditation during the time period the provider is actively seeking accreditation. This time period may not exceed two hundred calendar days. 6. Nothing in this rule shall preclude a practitioner of one or more of the services that is not employed by a provider from rendering those services to a recipient with a primary diagnosis of ASD and receiving reimbursement, as appropriate, for the provision of the services. 7. The treatment plan developed for the provision of services to a recipient with a primary diagnosis of ASD must include a description of the participation, by the recipient's parent or guardian in the treatment program. D. Exclusions: 1. Community psychiatric supportive treatment is not reimbursable when a recipient receives services from an ASD provider. 2. Services are reimbursable only when provided to a recipient twenty-one years of age or younger. 3. Nothing in this rule shall prohibit a physician group practice or other medical group practice from rendering services other than those listed above to a recipient with a diagnosis of autism spectrum disorder. 4. Reimbursement is not permitted under any of the following situations: a. Services or activities not stated in the treatment plan b. Services or activities based on experimental behavior methods or models c. Education and related services or activities as described by the individuals with disability education act (IDEA) d. Services or activities that are vocational in nature and otherwise available to the recipient through a program funded under Section 110 of the Rehabilitation Act of 1973 e. Services or activities that are a component of adult day care programs HMO, PPO, & Individual Marketplace Children's Intensive Behavioral Services (CIBS) interventions are medically necessary for 20 hours per week for members under the age of twenty-one who have been diagnosed with an autism spectrum disorder (ASD) when the criteria below are met.

4 A. The following definitions apply: 1. Assessment" means a functional behavior assessment 2. "Intervention" is an action taken to improve individual behaviors through methods based in scientific research, evidence-based practices, and published research and designs. 3. "Direct supervision" means a supervising provider who is immediately available in person to provide assistance and direction to the supervisee throughout the rendering of the service but is not required be present in the room where the supervisee is. 4. "General supervision" means that the supervising provider is available by telephone to provide assistance and direction if needed by the supervisee. 5. "Training" is an intervention focused on assisting the family or guardians of the CIBS eligible individual to use tools and gain the skills necessary for carrying out the behavioral interventions identified in the individual's treatment plan. B. Children's intensive behavioral service (CIBS) consists of the following components: 1. Assessment a. Assessments must determine the underlying function or purpose of a behavior in order to develop an effective treatment plan, and may include a variety of systematic information gathering techniques regarding factors influencing the occurrence of a behavior (e.g. antecedents, consequences, setting events and motivating operations) including interview, direct observation and experimental analysis, and systematic manipulation of environmental variables in an attempt to demonstrate a relationship between an environmental event and targeted behavior. b. All assessments require a signed order from a practitioner whose scope of practice includes the diagnosis and treatment of ASD c. Assessments include the development of a treatment plan and must have a clinical focus to assess behaviors which interfere with typical development. Tools to assess skills and behavior may be utilized and include, but are not limited to: The Assessment of Basic Language and Learning Skills (ABLLS); The Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP); or The Behavior Assessment System for Children, Second Edition (BASC-2). 2. Treatment plan d. The individual who developed the treatment plan shall be responsible for the implementation of the treatment plan. e. The treatment plan must include behavior analytic intervention methods proven to be effective, such as Applied Behavior Analysis (ABA), to address what was identified in the assessment. f. At a minimum, the treatment plan shall include the following: A written document describing the presenting behavior problem(s) and describing the behavioral goals and interventions selected to alter the behavior. The treatment plan shall be based on information gathered from in-person assessments, review of records from other professionals, direct observations, and clinical interview data, and includes the selected interventions, an estimate of the length of time and/or number of sessions anticipated to achieve the goals, and specific statements about the measurement of progress toward achieving the goals. Medical diagnosis identifying one of the following autism spectrum disorders (ASD): autistic disorder, childhood disintegrative disorder, Asperger s syndrome, or a pervasive developmental disorder; and The signatures of the practitioner responsible for implementing the treatment plan and the signatures of the parents or guardians involved in the care of the individual receiving CIBS services. 3. Interventions a. Interventions may be provided in an individual, family or group setting. b. Interventions must be focused on achieving the goals and addressing the needs identified in the treatment plan for the CIBS eligible individual. c. Interventions shall only be provided after an assessment has been performed and a treatment plan has been developed. d. Interventions must be rendered by eligible practitioners. e. Additional interventions may be requested through prior authorization. The prior authorization request must include a new assessment and copy of the treatment plan that meets the above criteria. 4. Training a. Training may be provided with or without the child present. b. Training must be child-centered and focused on training the family or guardians in developing the skills needed to address the ongoing needs of the CIBS eligible individual.

5 c. Training must assist the family or guardians to carry out behavior analytic interventions based on evidence-based practices, published research and designs. d. Training must include instruction in behavior interventions to the family or guardians and other supportive caregivers. 5. Ongoing review of progress, the frequency of which is determined by clinical review and/or applicable state laws, must be developed and documented by a licensed practitioner as defined in this policy and include ALL criteria, as well as: a. Upon request, a letter indicating the continued medical necessity from a licensed credentialed psychologist, psychiatrist, or developmental pediatrician that includes consideration of less intensive interventions and rationale for continued ABA therapy b. An updated individualized treatment plan noting specific measurable progress on targeted behaviors identified in initial treatment plan (e.g. frequency, rate, intensity and duration), and new or refined interventions evidencing individualized need and demonstrating the non-custodial nature of care. Updated criteria and specific behavioral goals and interventions for lesser intensity of care and discharge must be included; as well as documentation of updated parental or guardian involvement in prioritizing target behaviors and training in behavioral techniques in order to provide additional and supportive interventions C. Member eligibility for CIBS A member is eligible to receive the intervention component of CIBS when all the following are met: 1. The recipient is under the age of twenty-one 2. The recipient lives in a community setting 3. The recipient has a diagnosis of autistic disorder, childhood disintegrative disorder, Asperger s syndrome, or a pervasive developmental disorder as diagnosed by a practitioner whose scope of practice includes the diagnosis and treatment of ASD. 4. The completed assessment identifies the need for interventions. D. Eligible practitioners 1. The following practitioners may conduct assessments, render CIBS interventions, and supervise practitioners if applicable and consistent with scope of practice, education, training, and experience: a. A psychologist licensed by the state board of psychology b. A licensed professional clinical counselor (LPCC), licensed independent social worker (LISW), or licensed independent marriage and family therapist (LIMFT) licensed by the state counselor, social worker, and marriage and family therapist (CSWMFT) board c. A certified state behavioral analyst certified by the state board of psychology d. A professional medical group consisting of providers meeting the qualifications listed above. e. A school program employing or contracting with at least one of the following: A provider meeting the qualifications listed above A school psychologist licensed by the state board of psychology 2. The following practitioners may only render the interventions set forth in the treatment plan of a CIBS eligible individual as applicable within their scope of practice and consistent with their education, training, and experience: f. A licensed professional counselor (LPC), licensed social worker (LSW), or marriage and family therapist licensed (MFT) by the state CSWMFT board. Such practitioners must: Work under the general supervision of one of the providers listed above. Be trained regarding the implementation of the treatment plan by the supervisor. g. A paraprofessional who possesses at least a bachelor s degree in psychology, special education, or a related discipline. Such practitioners must: Work under the direct supervision of one of the providers listed above; or If acting on the license of and working under the direct supervision of one of the providers listed above, the paraprofessional must be registered with the appropriate licensing board as a trainee, assistant, or intern as applicable; or If operating under a school program, be supervised by a school psychologist; and Have documented evidence of receiving formal instruction in social and behavioral interventions for children with autism spectrum disorder; Have experience providing one-on-one behavior-focused interventions for individuals with a developmental delay or disability; Have received training in CIBS recipient-specific techniques from the supervisor; and Have been trained regarding the implementation of the treatment plan by the supervisor.

6 E. Services and activities not reimbursable under CIBS include, but are not limited to: 1. Services not identified in the approved treatment plan 2. Experimental behavioral methods or models 3. Services including nonhuman elements, including animal therapy 4. Sex therapy, psychoanalysis, or hypnotherapy 5. Education and related services as described by the individuals with disability education act (IDEA) 6. Vocational services that are otherwise available to the child through a program funded under Section 110 of the Rehabilitation Act of Services required as a component of adult day care programs F. Limitations 1. A maximum of four hours of assessments are allowed per consecutive twelve month period. This limit may be exceeded if medically necessary through prior authorization. 2. A provider of CIBS, who is a family member or guardian of the CIBS eligible individual, shall not be reimbursed for services under this rule. 3. Community Psychiatric Supportive Treatment (CPST) is not reimbursable when an individual is receiving CIBS interventions as part of an approved treatment plan. 4. CIBS interventions are not reimbursable under Therapeutic Behavioral Services (TBS) and Psychosocial Rehabilitation (PSR). CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CPT CODES Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionaires), each 15 minutes face-to-face with the patient; initial assessment Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionaires), each 15 minutes face-to-face with the patient; re-assessment Health and behavior intervention, each 15 minutes, face-to-face; individual Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present) 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 (List separately in addition to code for primary service) 0362T 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 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 (List separately in addition to code for primary procedure) 0364T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time 0365T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) 0366T Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time 0367T Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) 0368T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time 0369T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure) 0370T Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)

7 0371T 0372T 0373T 0374T Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-toface with multiple patients Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in addition to code for primary procedure) TAWG REVIEW DATES: 12/17/2015, 02/26/2016, 07/22/2016 REVISION HISTORY EXPLANATION 12/17/15: Policy created to reflect most current clinical evidence per TAWG. 02/26/16: Applied Behavior Analysis (0359T-0374T) may be covered with prior authorization for Advantage. Policy reviewed and updated to reflect most current clinical evidence per TAWG. 07/22/16: Policy reviewed and updated to reflect most current clinical evidence per TAWG. 02/14/17: Applied Behavior Analysis (0359T-0374T) is non-covered for Advantage. For Advantage members, Paramount defers to the Ohio Department of Mental Health and Addiction Services providers for access, delivery and payment of these services. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 05/09/17: Changed title from Applied Behavioral Analysis (ABA) to Children's Intensive Behavioral Service/Applied Behavioral Analysis (ABA). Added codes as covered with prior authorization for HMO, PPO, & Individual Marketplace and non-covered for Elite & Advantage. Applied Behavior Analysis (0359T-0374T) is now covered with prior authorization for Ohio HMO, PPO, & Individual Marketplace. 20 hours per week limit for Children's Intensive Behavioral Service. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 07/10/18: Effective 07/01/18 codes 0359T, 0364T, 0365T, 0368T, & 0369T are now be covered with prior authorization for Advantage per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT ) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.