OPTUM LEVEL OF CARE GUIDELINES: INTENSIVE BEHAVIORAL THERAPY / APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER HAWAII MEDICAID QUEST LEVEL OF CARE GUIDELINES: INTENSIVE BEHAVIORAL THERAPY/APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER HAWAII MEDICAID QUEST Guideline Number: Effective Date: February, 2018 INSTRUCTIONS FOR USE This guideline is used t make cverage determinatins as well as t infrm discussins abut evidence-based practices and discharge planning fr behaviral health benefit plans managed by Optum 1. When deciding cverage, the member s specific benefits must be referenced. All reviewers must first identify member eligibility, the member-specific benefit plan cverage, and any federal r state regulatry requirements that supersede the member s benefits prir t using this guideline. Other clinical criteria may apply. Optum reserves the right, in its sle discretin, t mdify its clinical criteria as necessary using the prcess described in Clinical Criteria. This guideline is prvided fr infrmatinal purpses. It des nt cnstitute medical advice. Optum may als use tls develped by third parties that are intended t be used in cnnectin with the independent prfessinal medical judgment f a qualified health care prvider and d nt cnstitute the practice f medicine r medical advice. Optum may develp clinical criteria r adpt externally-develped clinical criteria that supersede this guideline when required t d s by cntract r regulatin. INTENSIVE BEHAVIOR THERAPY / APPLIED BEHAVIOR THERAPY INTENSIVE BEHAVIOR THERAPY / APPLIED BEHAVIOR THERAPY is a reliable, evidence-based behavir interventin prgram designed t develp r restre the functining f an individual diagnsed with Autism Spectrum Disrder. The curse f IBT is fcused n addressing the factrs that precipitated admissin (e.g., changes in the member s signs and symptms, psychscial and envirnmental factrs, r level f functining) t the pint that the factrs that precipitated treatment n lnger require treatment. Optum is a brand used by United Behaviral Health and its affiliates. Intensive Behavir Therapy fr Autism Spectrum Disrder-Hawaii Medicaid QUEST Cntract Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 1 f 5
The service is nt Lng-Term Services and Supprts (LTSS), Hme and Cmmunity Based Services (HCBS), r Respite Services. 1. Admissin Criteria see Cmmn Criteria and Best Practices fr All Levels f Care : https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinicalresurces/guidelines-plicies/lcg.html The member current signs and symptms meet criteria fr Autism Spectrum Disrder, r Autism Spectrum Disrder is prvisinally diagnsed. In the event that the member is prvisinally diagnsed with Autism Spectrum Disrder, the member may qualify fr up t a 26-week trial f Applied Behavir Analysis when the criteria in this guideline are therwise met. Services are medically necessary i Treatment is nt cvered when any f the fllwing apply: 2. Cntinued Service Criteria 3. Discharge Criteria Care is primarily custdial in nature; Beneficiary is nt medically stable; Services are prvided by family r husehld members; Treatment is prvided as Lng Term Services and Supprts (LTSS), Hme and Cmmunity Based Services (HCBS), r respite services; Treatments are cnsidered experimental r lack scientifically prven benefit; r Services are prvided by a Hawaii prvider utside f the State. see Cmmn Criteria and Best Practices fr All Levels f Care : https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinicalresurces/guidelines-plicies/lcg.html see Cmmn Criteria and Best Practices fr All Levels f Care : https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinicalresurces/guidelines-plicies/lcg.html 4. Clinical Best Practices see Cmmn Criteria and Best Practices fr All Levels f Care : https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinicalresurces/guidelines-plicies/lcg.html see als the Behaviral Clinical Plicy, Intensive Behaviral Therapy / Applied Behavir Analysis fr Autism Spectrum Disrder : https://ubhweb.uhc.cm/ubh/clinical_plicy_standards/gls/behaviralclinicalplicies.htm l A diagnstic evaluatin is cnducted by any f the fllwing: Develpmental behaviral pediatrician Develpmental pediatrician Neurlgist Pediatrician Psychiatrist Psychlgist Intensive Behavir Therapy fr Autism Spectrum Disrder-Hawaii Medicaid QUEST Cntract Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 2 f 5
REFERENCES* Other license prvider with expertise in Autism Spectrum Disrder The prvider cnducting the diagnstic evaluatin refers a member wh either meets the criteria fr Autism Spectrum Disrder r wh is prvisinally diagnsed with Autism Spectrum Disrder fr further assessment and treatment plan develpment. Further assessment may be perfrmed by the prvider wh cnducted the diagnstic evaluatin, r either f the fllwing: Bard-Certified Behaviral Dctrate (BCBA-D) Bard-Certified Behaviral Analyst (BCBA) A prvider with expertise in Applied Behavir Analysis develps the treatment plan and prvides treatment. In additin t the types f prviders listed abve, treating prviders may be either f the fllwing: Bard-Certified Assistant Behavir Analyst (BCaBA) Registered Behavir Technician (RBT) perfrming under the supervisin f a BCBA, BCaBA, r BCBA-D The treatment plan: Addresses the identified behaviral, psychlgical, family and medical cncerns; Has measurable gals in bjective and measurable terms based n frmalized assessments. The assessments address skill acquisitin, the behavirs, and impairments fr which the interventin is t be applied. Dcument that services will be delivered by a rendering prvider wh is licensed accrding t the requirements f the State f Hawaii s Medicaid Prgram. Fr each gal in the treatment plan, the prvider dcuments a re-evaluatin f prgress tward treatment gals cmpleted n later than 24 weeks after treatment began in rder t establish a baseline in the areas f scial skills, cmmunicatin skills, language skills, behavir change, and adaptive functining. The re-evaluatin cmpares prgress with the member s baseline. The re-evaluatin anticipates the timeline and treatment hurs fr achievement f each gal based n bth the initial assessment and subsequent re-evaluatins ver the duratin f treatment. The prvider affrds dcumentatin f prgress tward treatment gals at least every 26 weeks including results frm generally accepted measurement systems such as the Verbal Behavir Milestnes Assessment (VB-MAPP) r Assessment f Basic Language and Learning Skills-Revised (ABLL-R ). When a member is underging a 26-week trial f Applied Behavir Analysis, dcumentatin is affrded at least every 12 weeks. The treatment plan shuld be reviewed sner when there has been a change in the member s cnditin, r the member s cnditin is nt imprving r it has wrsened. When the member s cnditin has nt imprved r it has wrsened, the reassessment shuld determine whether the diagnsis is accurate, the treatment plan shuld be mdified, r the member s cnditin shuld be treated in anther level f care. State f Hawaii, Department f Human Services. (2015). Cverage f Intensive Behaviral Therapy (IBT) fr Treatment f Children Under 21 Years f Age with Autism Spectrum Disrder (ASD). State f Hawaii, Hawaii Revised Statutes. (2013). 432E-1.4, Medical Necessity. *Additinal reference materials can be fund in the reference sectin(s) f the applicable Level f Care Guidelines and in the related Behaviral Clinical Plicy. HISTORY/REVISION INFORMATION Date Octber, 2015 Versin 1 December, 2016 Versin 2 Actin/Descriptin Intensive Behavir Therapy fr Autism Spectrum Disrder-Hawaii Medicaid QUEST Cntract Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 3 f 5
Date January, 2017 Versin 3 February, 2018 Versin 4 Actin/Descriptin i Per State f Hawaii Revised Statutes 432E-1.4, fr cntractual purpses, a health interventin shall be cvered if it is an therwise cvered categry f service, nt specifically excluded, recmmended by the treating licensed health care prvider, and determined by the health plan's medical directr t be medically necessary as defined in subsectin (b). A health interventin may be medically indicated and nt qualify as a cvered benefit r meet the definitin f medical necessity. A managed care plan may chse t cver health interventins that d nt meet the definitin f medical necessity. (b) A health interventin is medically necessary if it is recmmended by the treating physician r treating licensed health care prvider, is apprved by the health plan's medical directr r physician designee, and is: (1) Fr the purpse f treating a medical cnditin; (2) The mst apprpriate delivery r level f service, cnsidering ptential benefits and harms t the patient; (3) Knwn t be effective in imprving health utcmes; prvided that: (A) Effectiveness is determined first by scientific evidence; (B) If n scientific evidence exists, then by prfessinal standards f care; and (C) If n prfessinal standards f care exist r if they exist but are utdated r cntradictry, then by expert pinin; and (4) Cst-effective fr the medical cnditin being treated cmpared t alternative health interventins, including n interventin. Fr purpses f this paragraph, cst-effective shall nt necessarily mean the lwest price. (c) When the treating licensed health care prvider and the health plan's medical directr r physician designee d nt agree n whether a health interventin is medically necessary, a reviewing bdy, whether internal t the plan r external, shall give cnsideratin t, but shall nt be bund by, the recmmendatins f the treating licensed health care prvider and the health plan's medical directr r physician designee. (d) Fr the purpses f this sectin: "Cst-effective" means a health interventin where the benefits and harms relative t the csts represent an ecnmically efficient use f resurces fr patients with the medical cnditin being treated thrugh the health interventin; prvided that the characteristics f the individual patient shall be determinative when applying this criterin t an individual case. "Effective" means a health interventin that may reasnably be expected t prduce the intended results and t have expected benefits that utweigh ptential harmful effects. "Health interventin" means an item r service delivered r undertaken primarily t treat a medical cnditin r t maintain r restre functinal ability. A health interventin is defined nt nly by the interventin itself, but als by the medical cnditin and patient indicatins fr which it is being applied. New interventins fr which clinical trials have nt been cnducted and effectiveness has nt been scientifically established shall be evaluated n the basis f prfessinal standards f care r expert pinin. Fr existing interventins, scientific evidence shall be cnsidered first and, t the greatest extent pssible, shall be the basis fr determinatins f medical necessity. If n scientific evidence is available, prfessinal standards f care shall be cnsidered. If prfessinal standards f care d nt exist r are utdated r cntradictry, decisins abut existing interventins shall be based n expert pinin. Giving pririty t scientific evidence shall nt mean that cverage f existing interventins shall be denied in the absence f cnclusive scientific evidence. Existing interventins may meet the definitin f medical necessity in the absence f scientific evidence if there is a strng cnvictin f effectiveness and benefit expressed thrugh up-t-date and cnsistent prfessinal standards f care, r in the absence f such standards, cnvincing expert pinin. "Health utcmes" mean utcmes that affect health status as measured by the length r quality f a patient's life, primarily as perceived by the patient. "Medical cnditin" means a disease, illness, injury, genetic r cngenital defect, pregnancy, r a bilgical r psychlgical cnditin that lies utside the range f nrmal, age-apprpriate human variatin. "Physician designee" means a physician r ther health care practitiner designated t assist in the decisin-making prcess wh has training and credentials at least equal t the treating licensed health care prvider. "Scientific evidence" means cntrlled clinical trials that either directly r indirectly demnstrate the effect f the interventin n health utcmes. If cntrlled clinical trials are nt available, bservatinal studies that demnstrate a causal relatinship between the interventin and the health utcmes may be used. Partially cntrlled bservatinal studies and uncntrlled clinical series may be suggestive, but d nt by themselves demnstrate a causal relatinship unless the magnitude f the effect bserved exceeds anything that culd be explained either by the natural histry f the medical cnditin r ptential experimental biases. Scientific evidence may be fund in the fllwing and similar surces: (1) Peer-reviewed scientific studies published in r accepted fr publicatin by medical jurnals that meet natinally recgnized requirements fr scientific manuscripts and that submit mst f their published articles fr review by experts wh are nt part f the editrial staff; (2) Peer-reviewed literature, bimedical cmpendia, and ther medical literature that meet the criteria f the Natinal Institutes f Health's Natinal Library f Medicine fr indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS database Health Services Technlgy Assessment Research (HSTAR); (3) Medical jurnals recgnized by the Secretary f Health and Human Services under sectin 1861(t)(2) f the Scial Security Act, as amended; (4) Standard reference cmpendia including the American Hspital Frmulary Service-Drug Infrmatin, American Medical Assciatin Drug Evaluatin, American Dental Assciatin Accepted Dental Therapeutics, and United States Pharmacpeia-Drug Infrmatin; Intensive Behavir Therapy fr Autism Spectrum Disrder-Hawaii Medicaid QUEST Cntract Prprietary Infrmatin f Optum. 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(5) Findings, studies, r research cnducted by r under the auspices f federal agencies and natinally recgnized federal research institutes including but nt limited t the Federal Agency fr Health Care Plicy and Research, Natinal Institutes f Health, Natinal Cancer Institute, Natinal Academy f Sciences, Centers fr Medicare and Medicaid Services, Cngressinal Office f Technlgy Assessment, and any natinal bard recgnized by the Natinal Institutes f Health fr the purpse f evaluating the medical value f health services; and (6) Peer-reviewed abstracts accepted fr presentatin at majr medical assciatin meetings. Intensive Behavir Therapy fr Autism Spectrum Disrder-Hawaii Medicaid QUEST Cntract Prprietary Infrmatin f Optum. Cpyright 2018 Optum, Inc. Page 5 f 5