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| CoveragePolicy #: | 1028 | |
| Category: | Medicine | |
| Initiated: | January 1, 2016 | |
| Last Review: | December 22, 2025 | |
| Last Revision: | March 5, 2026 | |
Skai Blue Cross Blue Shield National Accounts Coverage Policy for Participants and Beneficiaries enrolled in Walmart Associates' Medical Plan (AMP) (Developed by Skai Blue Cross Blue Shield and Adopted by the Walmart AMP as Plan Coverage Criteria)
Autism Spectrum Disorder, Applied Behavior Analysis
| Description: |
Autism spectrum disorder (ASD) is a complex, pervasive developmental disability characterized by variable social and communicative deficits with repetitive, restricted behaviors and for many, significant cognitive impairment. The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, Text Revision (DSM-V-TR) specifies autistic disorder, pervasive developmental disorder---not otherwise specified (PDD-NOS), and Asperger’s syndrome as included under the diagnosis of ASD. DSMV coalesces all of these diagnoses into Autism spectrum Disorder. The Center for Disease Control (CDC) estimates the prevalence of ASD as 1 out of every 68 children occurring in all ethnic, racial, and socioeconomic groups but 4-5 times more likely in boys than girls. A CDC report published in 2009, demonstrated that an average of 41% of ASD individuals met a definition of intellectual disability.
Applied Behavioral Analysis (ABA) is the behavioral treatment approach most commonly used with children with ASD. Techniques based on ABA include: Discrete Trial Training, Incidental Teaching, Pivotal Response Training, and Verbal Behavioral Intervention. ABA involves a structured environment, predictable routines, individualized treatment, transition and aftercare planning, and significant family involvement. ABA attempts to increase skills related to behavioral deficits and reduce behavioral excesses. Behavioral deficits may occur in the areas of communication, social and adaptive skills, but are possible in other areas as well. Examples of deficits may include: a lack of expressive language, inability to request items or actions, limited eye contact with others, and inability to engage in age-appropriate self-help skills such as tooth brushing or dressing. Examples of behavioral excesses may include, but are not limited to physical aggression, property destruction, elopement, self-stimulatory behavior, self-injurious behavior, and vocal stereotypy. Several discipline- specific intensive intervention programs have been developed and advocated for the treatment of autism (Lovaas therapy, Early Start Denver Model, and others).
ABA treatment is considered either comprehensive or focused based on the core symptoms targeted and the intensity of the intervention.
SERVICE INTENSITY CLASSIFICATION:
Comprehensive treatments range from 25 to 40 total hours of direct services weekly. The behavioral health benefits management program will review each request on an individual basis for fidelity to medical necessity and approve total hours based on the member’s severity, intensity, frequency of symptoms and response to previous and current ABA treatment. Comprehensive treatment includes direct 1:1 ABA, caregiver training, supervision and treatment planning.
Comprehensive ABA treatment targets members whose treatment plans address deficits in all core symptoms of Autism. Appropriate examples of comprehensive treatment include early intensive behavioral intervention and treatment programs for older children with aberrant behaviors across multiple settings. This treatment level, which requires very substantial support, should initially occur in a structured setting with 1:1 staffing and should advance to the least restrictive environment appropriate for the member. This treatment is primarily directed to children ages 3 to 8 years old because Comprehensive ABA treatment has been shown to be most effective with this population in current medical literature. Caregiver training is an essential component of Comprehensive ABA treatment.
Focused treatments range from 10 to 15 total hours of direct services per week. The behavioral health benefits management program will review each request on an individual basis for fidelity to medical necessity and approve total hours based on the member’s severity, intensity, frequency of symptoms and response to previous and current ABA treatment. This treatment may include individual services, group services and caregiver training. Focused treatment typically targets a limited number of behavior goals requiring support of ABA treatment. Behavioral targets include marked deficits in social communication skills and restricted, repetitive behavior such as difficulties coping with change. In cases of specific aberrant and/or restricted, repetitive behaviors, attention to prioritization of skills is necessary to prevent and offset exacerbation of these behaviors, and to teach new skill sets. Identified aberrant behaviors should be addressed with specific procedures outlined in a Behavior Intervention Plan. Emphasis is placed on group work and caregiver training to assist the member in developing and enhancing his/her participation in family and community life, and developing appropriate adaptive, social or functional skills in the least restrictive environment. Requested treatment hours outside of the range for Comprehensive or Focused treatment will require a specific clinical rationale.
Coding
Effective January 1, 2019, there are new CPT category I codes for applied behavioral analysis and are billed in 15 minute units. These services were previously billed with Category III codes in 30 minute or 1 hour units. Coding instructions using the new CPT category I codes are listed below in the Policy/Coverage section.
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| Policy/Coverage: |
Effective March 01, 2026
Prior Authorization of Services:
All requests for coverage of ABA treatment will require preauthorization. Preauthorization means that services are reviewed and meet all of the coverage criteria defined in this policy. Preauthorization should be done prior to services being provided.
Preauthorization and concurrent review is required for all ABA services and will be administered by a benefits management program specific to the member’s plan. Please call the number on the back of the member’s Plan ID card for more information.
Walmart Health Plan provides coverage for applied behavioral analysis (ABA) as Medically Necessary for those individuals with a confirmed diagnosis of autism spectrum disorder and a signed prescription from a licensed physician or licensed psychologist for ABA treatment in accordance with ALL of the below parameters and guidelines:
Comprehensive and Focused Treatment will be subject to coverage criteria limits as managed by the benefits management program specific to the member’s plan.
Comprehensive and Focused Treatment cannot be provided concurrently.
Telehealth/Telemedicine
Requests for telehealth/telemedicine ABA services will be reviewed in accordance with current controlling health plan guidelines. The delivery of direct ABA services by telehealth/telemedicine (e.g., 97152, 97153, 97154, 0372T, 0373T) are not covered.
Telehealth/telemedicine for parent education (e.g., 97156 and 97157), direct supervision activities (e.g., 97155, 97158), and some assessment activities (97151) may be covered if allowed as an eligible telehealth/telemedicine service under the member benefit plan. These may account for only 50% of services (by code) unless extenuating circumstances are prior approved.
POLICY GUIDELINES:
All requests will require a multidisciplinary evaluation to include, at a minimum, formal testing and assessment by the following providers (who are not employed by the child’s educational institution):
Suggested testing by the multidisciplinary team normally includes:
Medical Necessity: Medical necessity is defined in the controlling specific health plan and/or group documents.
Definitions:
Please refer to Guidelines for Treatment Record Documentation section of the behavioral health benefits management program provider manual for standards on client file documentation.
The behavioral health benefits management program will review requests for ABA treatment benefit coverage based upon clinical information submitted by the provider.
COVERAGE CRITERIA FOR ABA SERVICES FOR ELIGIBLE MEMBERS
The behavioral health benefits management program authorizes ABA services for ASD when the following comprehensive diagnostic evaluation criteria are met:
ABA Pre-Treatment Assessment Request
Must meet all the following criteria:
Note: Only CPT codes identified in this document will be approved for the ABA assessment process. Standardized psychological testing services are billed with specific psychological testing AMA-CPT code by eligible providers. Typically, only a clinical psychologist is qualified to provide testing services.
Initial ABA Treatment Authorization Request
Must meet all the following criteria:
Continued ABA Treatment Authorization Request
Must meet all the following criteria
HOURS TO BE AUTHORIZED:
Total authorized hours will be determined based on all of the following:
Coding Guidelines
Concurrent billing of 97153 and 97155 is not allowed (unless 97155 is a separate, distinct service from 97153).
Out of State claims coding:
ABA service providers who are in network with their local Blue Cross and Blue Shield and who are contracted to use ABA service codes different from the approved list will be eligible for reimbursement for service codes that are equivalent to covered ABA service codes listed above. Service codes that are not equivalent to the approved service codes are not eligible for reimbursement. Approval for use of alternate service codes can be requested during the provision of ABA services.
CPT Definition of Time Spent with Patient that is Eligible for Reimbursement:
Face-to-face time for outpatient visits is reimbursable and includes:
Activities such as review of records, arranging further services, communicating with other professionals (health care, teachers, etc.) and family are considered non-face to face services provided to the member. These may occur before or after the member visit. Providing these non-face to face services are included in the work for codes 97151 to 97158 and codes 0362T and 0373T. The non-face-to-face activities are not eligible for claims submission independent of face-to-face time. (CPT 2021).
Applied behavioral analysis for individuals with Autism Spectrum Disorder not meeting the criteria listed above, is considered Not Medically Necessary and is not covered or is Investigational.
Applied behavioral analysis for all other diagnoses and indications, other than Autism Spectrum Disorder, is considered Not Medically Necessary and is not covered or is Investigational.
Treatments other than ABA do not fall under the scope of this policy and are considered Not Medically Necessary and are not covered or are Investigational, including but not limited to:
Not Medically Necessary or Investigational services are Plan exclusions.
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| Policy/Coverage-Prior: |
Effective February 01, 2026 to February 28, 2026
Walmart Health Plan provides coverage for applied behavioral analysis (ABA) for those individuals with a confirmed diagnosis of autism spectrum disorder as medically necessary and a signed prescription from a licensed physician or licensed psychologist for ABA treatment in accordance with ALL of the below parameters and guidelines:
Prior Authorization of Services:
All requests for coverage of ABA treatment will require preauthorization. Preauthorization means that services are reviewed and meet all of the coverage criteria defined in this policy. Preauthorization should be done prior to services being provided.
Preauthorization and concurrent review is required for all ABA services and will be administered by a benefits management program specific to the member’s plan. Please call the number on the back of the member’s Plan ID card for more information.
*Comprehensive and Focused Treatment cannot be provided concurrently.
Treatments other than ABA do not fall under the scope of this policy; these services include but are not limited to treatments that are considered to be investigational/experimental, such as Cognitive Training; Auditory Integration Therapy; Facilitated Communication; Higashi Schools/Daily Life; Individual Support Program; LEAP; SPELL; Waldon; Hanen; Early Bird; Bright Start; Social Stories; Gentle Teaching; Response Teaching Curriculum and Developmental Intervention Model; Holding Therapy; Movement Therapy; Music Therapy; Pet Therapy; Psychoanalysis; Son-Rise Program; Scotopic Sensitivity Training; Sensory Integration Training; Neurotherapy (EEG biofeedback)
For all other diagnoses and indications, applied behavioral analysis (ABA) is not covered.
Requests for telehealth/telemedicine ABA services will be reviewed in accordance with current controlling health plan guidelines. The delivery of direct ABA services by telehealth/telemedicine (e.g., 97152, 97153, 97154, 0372T, 0373T) are not covered.
Telehealth/telemedicine for parent education (e.g., 97156 and 97157), direct supervision activities (e.g., 97155, 97158), and some assessment activities (97151) may be covered if allowed as an eligible telehealth/telemedicine service under the member benefit plan. These may account for only 50% of services (by code) unless extenuating circumstances are prior approved.
POLICY GUIDELINES:
Eligibility determination for ABA services:
All requests will require a multidisciplinary evaluation to include, at a minimum, formal testing and assessment by the following providers (who are not employed by the child’s educational institution):
Required testing by the multidisciplinary team normally includes:
MEDICAL NECESSITY:
Medical necessity is defined in the controlling specific health plan and/or group documents.
Definitions:
Please refer to Guidelines for Treatment Record Documentation section of the behavioral health benefits management program provider manual for standards on client file documentation.
The behavioral health benefits management program will review requests for ABA treatment benefit coverage based upon clinical information submitted by the provider.
COVERAGE CRITERIA FOR ABA SERVICES FOR ELIGIBLE MEMBERS
COVERAGE GUIDELINES: INITIAL SERVICE REQUEST
The behavioral health benefits management program authorizes ABA services for ASD when the following comprehensive diagnostic evaluation criteria are met:
COMPREHENSIVE DIAGNOSTIC EVALUATION:
ABA SERVICE REQUEST FOR ASSESSMENT
MUST MEET ALL OF THE FOLLOWING:
Note: Only CPT or HCPCS codes identified in this document will be approved for, the ABA assessment process. Standardized psychological testing services are billed with specific psychological testing AMA-CPT code by eligible providers. Typically, only a clinical psychologist is qualified to provide testing services.
INITIAL ABA AUTHORIZATION REQUEST
MUST MEET ALL OF THE FOLLOWING:
CONTINUED ABA AUTHORIZATION REQUEST
Member must demonstrate clinically significant improvement or progress achieving goals for successive
authorization periods or benefit coverage of ABA services may be reduced or denied.
MUST MEET ALL OF THE FOLLOWING:
HOURS TO BE AUTHORIZED:
Total authorized hours will be determined based on all of the following:
Caseload Size
The Council on Autism Service Provider’s (CASP) Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers, 2nd Edition states that Behavior Analysts should carry a caseload that allows them to provide appropriate case supervision to facilitate effective treatment delivery and ensure consumer protection.
Caseload size for the Behavior Analyst is typically determined by the following factors:
The recommended caseload range for one (1) Behavior Analyst is as follows:
Supervising Focused Treatment
Additional Assistant Behavior Analysts permit modest increases in caseloads.
* Focused treatment for severe problem behavior is complex and requires considerably greater levels of case supervision, which will necessitate smaller caseloads.
Supervising Comprehensive Treatment
Additional Assistant Behavior Analysts permit modest increases in caseloads
DIAGNOSTIC INSTRUMENTS/ASSESSMENTS:
Screening Measures: These are brief assessments designed to identify children who need of a comprehensive evaluation secondary to risks associated with delay, disorder or disease that will interfere with normal development. Screening measures differ from diagnostic measures in that they typically require less time and training to administer and have high rates of false positives. Results of screening measures indicate the level of risk for disability as opposed to the provision of a diagnosis. Screening measures are not appropriate standalone support for an autism diagnosis and should be followed up by an in-depth assessment. Additional acceptable documentation includes autism specific standardized assessments or a detailed clinical note based on the DSM-5 signs and symptoms. Examples of screening measures include:
Autism Spectrum Rating Scale (ASRS), long or short form
Childhood Autism Rating Scale, second edition. (CARS-2)
Childhood Autism Spectrum Test. (CAST)
Social Communications Questionnaire (SCQ)
Autism Behavior Checklist (ABC)
Gillian Autism Rating Scale (GARS)
Checklist for Autism in Toddlers (CHAT)
MCHAT R F with follow up questions (score 3-7)
MCHAT R without follow up questions (score 8-20)
Diagnostic Assessments: These offer significant detail concerning specific deficits and/or survey a broader swath of core behaviors in autism. Reliability and validity of the instrument are defined in depth. Reliability gauges the extent to which the instrument is free from measurement errors across time, across raters and within the test. Validity is the degree to which other evidence supports inferences drawn from the scores yielded by the instrument. This is often grouped into content, construct and criteria related evidence. These assessments also provide a measure for severity of illness.
Standardized Autism Diagnostic Assessments
Autism Diagnostic Observation Schedule, second edition. (ADOS-2)
Autism Diagnostic Interview, revised. (ADI-R)
Social Responsiveness Scale, second edition. (SRS-2)
DSM-5 Checklist
Standardized Adaptive Behavior Assessment Instruments
Adaptive assessments are a type of psychological testing, which is vetted, standardized and norm referenced. These assessments provide a pathway to allow comparison of an individual member’s score to a norm-referenced mean.
Vineland Adaptive Behavior Scale (VABS)
Adaptive Behavior Assessment Scale (ABAS)
Behavior Assessment System for Children (BASC)
Pervasive Developmental Disorder Behavior Inventory (PDDBI)
Standardized Cognitive Assessments
Leiter International Performance Scale-R
Mullen Scales of Early Learning
Bayley Scales of Infant Development
Kaufmann Assessment Battery for Children, second edition. (K-ABC-II)
Wechsler Preschool and Primary Scale of Intelligence, third edition. (WPPSI-III)
Wechsler Intelligence Scale for Children, fourth edition. (WISC-IV)
Test of Non-Verbal Intelligence, fourth edition (TONI-4)
Non-Standardized Curricular Assessments
These tools are developed to provide a curriculum-based individual assessment. They are criterion-referenced, as opposed to psychological testing, which is vetted, standardized and norm referenced. The latter provide a pathway to allow comparison of an individual member’s score to a norm-referenced mean. Examples include:
Assessment of Basic Language and Learning Skills (ABLLS)
Verbal Behavior Milestones Assessment and Placement Program (VBMAPP)
PEAK
Essentials For Living (EFL)
Assessment of Functional Living Skills (AFLS)
For those plans subject to Act 196 of the General Assembly of the State of Arkansas enacted as of October 1, 2011, the coverage of Applied Behavioral Analysis (ABA) may be subject to other general exclusions and limitations of the health insurance plan, including without limitation, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of health care services including review of medical necessity, case management, and other managed care provisions.
CPT Codes
All ABA codes are billed in 15-minute units. “If the Behavior Analyst or other qualified healthcare professional personally performs the line technician activities, his or her time engaged in these activities should be included as part of the line technician’s time to meet the components of the code.” AMA CPT, 2021, page 786
97151 BEHAVIOR IDENTIFICATION ASSESSMENT
97152 BEHAVIOR IDENTIFICATION SUPPORTING ASSESSMENT
Behavior identification-supporting assessment will require rationale and only face-to-face time by one provider/line therapist is reimbursable.
97153 ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL
97154 GROUP ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL
97155 ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL MODIFICATION
Clinical rationale must be provided for requests that exceed 2 hours of adaptive behavior treatment protocol modification per 10 hours of adaptive behavior treatment by protocol.
Adaptive treatment protocol modification may include the following: design, analysis and edits to antecedent or consequence strategies, individualized behavior plan based on functions maintaining aberrant behavior, inclusion of additional acquisition/replacement skills to current treatment plan or analysis and editing of prompt fading, chaining, differential reinforcement or generalization procedures, which require the expertise of the Behavior Analyst.
The following examples would not be considered protocol modification for purposes of billing 97155 and are part of the 97153 and 97154 codes: conducting preference assessments and altering reinforcement and/or implementation of skill acquisition and behavior reduction programs.
Only face-to-face time may be billed. Pre/post time including direction of line therapist without the member present and analysis of data collection are included in the valuation of the code reimbursement. The technician’s time (97153) may not be billed concurrently and is a component included in the valuation of his code.
97156 FAMILY ADAPTIVE BEHAVIOR TREATMENT GUIDANCE
97157 MULTIPLE FAMILY GROUP ADAPTIVE BEHAVIOR TREATMENT GUIDANCE
This code is typically used during the initial treatment phase to educate and orient families in ABA behavioral nomenclature and techniques
97158 GROUP ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION
This code entails differentiating prompting methods, instruction, antecedent/consequence strategies, varying goals/skills and reinforcement schedules in real time with multiple members simultaneously
0362T BEHAVIOR IDENTIFICATION SUPPORTING ASSESSMENT WITH FOUR REQUIRED
COMPONENTS
Behavior Analyst /qualified healthcare professional shapes environmental or social contexts to examine triggers, events, cues, responses and consequences linked to maladaptive destructive behaviors.
0373T ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION WITH FOUR
REQUIRED COMPONENTS
Out of State claims coding:
ABA service providers who are in network with their local Blue Cross and Blue Shield and who are contracted to use ABA service codes different from the approved list will be eligible for reimbursement for service codes that are equivalent to covered ABA service codes listed above. Service codes that are not equivalent to the approved service codes are not eligible for reimbursement. Approval for use of alternate service codes can be requested during the provision of ABA services.
CPT Definition of Time Spent with Patient that is Eligible for Reimbursement:
Face-to-face time for outpatient visits is reimbursable and includes:
Activities such as review of records, arranging further services, communicating with other professionals (health care, teachers, etc.) and family are considered non-face to face services provided to the member. These may occur before or after the member visit. Providing these non-face to face services are included in the work for codes 97151 to 97158 and codes 0362T and 0373T. The non-face-to-face activities are not eligible for claims submission independent of face-to-face time. (CPT 2021).
Applied behavioral analysis for individuals with Autism Spectrum Disorder not meeting the criteria listed above, is considered investigational and/or not medically necessary. Investigational and Not Medically Necessary services are Plan exclusions.
Applied behavioral analysis for all other diagnoses and indications, other than Autism Spectrum Disorder, is considered investigational and/or not medically necessary. Investigational and Not Medically Necessary services are Plan exclusions.
Treatments other than ABA do not fall under the scope of this policy and are considered investigational and/or not medically necessary and are not covered, including but not limited to:
Effective January 01, 2023 to January 31, 2026
Walmart Health Plan provides coverage for applied behavioral analysis (ABA) for those individuals with a confirmed diagnosis of autism spectrum disorder as medically necessary and a signed prescription from a licensed physician or licensed psychologist for ABA treatment in accordance with ALL of the below parameters and guidelines:
Prior Authorization of Services:
All requests for coverage of ABA treatment will require preauthorization. Preauthorization means that services are reviewed and meet all of the coverage criteria defined in this policy. Preauthorization should be done prior to services being provided.
Preauthorization and concurrent review are required for all ABA services and will be administered by a benefits management program specific to the member’s plan. Please call the number on the back of the member’s Plan ID card for more information.
*Comprehensive and Focused Treatment cannot be provided concurrently.
Treatments other than ABA do not fall under the scope of this policy; these services include but are not limited to treatments that are considered to be investigational/experimental, such as Cognitive Training; Auditory Integration Therapy; Facilitated Communication; Higashi Schools/Daily Life; Individual Support Program; LEAP; SPELL; Waldon; Hanen; Early Bird; Bright Start; Social Stories; Gentle Teaching; Response Teaching Curriculum and Developmental Intervention Model; Holding Therapy; Movement Therapy; Music Therapy; Pet Therapy; Psychoanalysis; Son-Rise Program; Scotopic Sensitivity Training; Sensory Integration Training; Neurotherapy (EEG biofeedback)
For all other diagnoses and indications, applied behavioral analysis (ABA) is not covered.
Requests for telehealth/telemedicine ABA services will be reviewed in accordance with current controlling health plan guidelines. The delivery of direct ABA services by telehealth/telemedicine (e.g., 97152, 97153, 97154, 0372T, 0373T) are not covered.
Telehealth/telemedicine for parent education (e.g., 97156 and 97157), direct supervision activities (e.g., 97155, 97158), and some assessment activities (97151) may be covered if allowed as an eligible telehealth/telemedicine service under the member benefit plan. These may account for only 50% of services (by code) unless extenuating circumstances are prior approved.
POLICY GUIDELINES (effective 01/01/2024):
Eligibility determination for ABA services:
All requests will require a multidisciplinary evaluation to include, at a minimum, formal testing and assessment by the following providers (who are not employed by the child’s educational institution):
Suggested testing by the multidisciplinary team normally includes:
Medical Necessity:
Medical necessity is defined in the controlling specific health plan and/or group documents.
Definitions:
Please refer to Guidelines for Treatment Record Documentation section of Lucet Behavioral Health Services and Solutions Provider Manual for standards on client file documentation.
Lucet Behavioral Health Services and Solutions will review requests for ABA treatment benefit coverage based upon clinical information submitted by the provider.
COVERAGE CRITERIA FOR ABA SERVICES
ABA Pre-Treatment Assessment Request
Must meet all the following criteria:
Initial ABA Treatment Authorization Request
Must meet all the following criteria:
Continued ABA Treatment Authorization Request
Must meet all the following criteria:
HOURS TO BE AUTHORIZED:
Total authorized hours will be determined based on all of the following:
Out of State claims coding:
ABA service providers who are in network with their local Blue Cross and Blue Shield and who are contracted to use ABA service codes different from the approved list will be eligible for reimbursement for service codes that are equivalent to covered ABA service codes listed above. Service codes that are not equivalent to the approved service codes are not eligible for reimbursement. Approval for use of alternate service codes can be requested during the provision of ABA services.
CPT Definition of Time Spent with Patient that is Eligible for Reimbursement:
Face-to-face time for outpatient visits is reimbursable and includes:
Activities such as review of records, arranging further services, communicating with other professionals (health care, teachers, etc.) and family are considered non-face to face services provided to the member. These may occur before or after the member visit. Providing these non-face-to- face services are included in the work for codes 97151 to 97158 and codes 0362T and 0373T. The non-face-to-face activities are not eligible for claims submission independent of face-to-face time. (CPT 2021).
02/06/24 - Policy guidelines updated
Due to the detail of this policy, the document containing the coverage statements for dates prior to January 01, 2023, are not online. If you would like a hardcopy print, please email the medical policy department.
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| Rationale: |
A total of fifteen studies were included for review (3 randomized, controlled trials (RCT) and 12 non-randomized, comparative studies) that met selection criteria. In one of the RCT’s (Sallows and Graupner, 2005), children in both the experimental and control groups improved significantly over time, but there was no statistically significant difference between groups. Another RTC (Smith, 2000), found significantly better cognitive and communication skills in the experimental group but no difference in adaptive skills. A more comprehensive and better constructed study, the Early Start Denver Model (Dawson et al, 2009) found significant improvement in IQ, language, and adaptive behavior in toddlers (18 to 30 months) who received 20 hours per week of therapy for 2 years compared to a control group of children who received community available therapy. Diagnostic assignment also improved significantly in the experimental group (29% improved from autistic disorder to PDD), but no significant change in ADOS severity scores.
The non-randomized, comparative studies include the seminal study by Lovaas et al (1987; McEachin, 1993). While these original studies involved a clinic-based ABA therapy program, other studies have compared home-based, community-based, school-based, residential, and outpatient programs. All of the studies were small, involved children between 15 months to 7 years of age, and utilized IBI at a high level (Lovaas, 40 hours/week of in center, therapist let treatment). They reported significant improvement in 47% of children with subsequent follow-up (McEachin, 1993) durable improvement sustained for 5 years. This study had a number of serious flaws: small sample size (n=59), no randomization, selection bias (exclusion of low-functioning autistic children), non-standard endpoints, focus on IQ and school placement overlooked other important social and behavioral impairments, and important differences in male:female ratios. In addition, review has suggested that a select subgroup of children were responsible for the overall changes in the intervention group: the 9 individuals described as “normal functioning” after treatment had a mean IQ gain of 37 points compared to the other 10 members of the intervention group who had a mean gain of only 3 points. Others note that this degree of improvement has not been replicated in any other subsequent study. Overall this research has been criticized for producing unrealistic expectations about the ability of EIBI to help ASD children attain normal developmental status.
In 2004, Shea noted that the results of these early studies have been misstated and misinterpreted by advocates of EIBI and called upon professionals to acknowledge that while EIBI may be beneficial in some ASD individuals, there is no evidence to point to “recovery” or cure. A systematic review by Bassett et al (2000) concluded that while many forms of EIBI benefit ASD, “there is insufficient, scientifically-valid effectiveness evidence to establish a causal relationship between a particular program of intensive, behavioral treatment, and the achievement of ‘normal functioning’.”
Within this category, [EIBI] report shows greater improvements in cognitive performance, language skills, and adaptive behavior skills than broadly defined eclectic treatments available in the community. However, strength of evidence is currently low. Further, not all children receiving intensive intervention demonstrate rapid gains, and many children continue to display substantial impairment. Although positive results are reported for the effects of intensive interventions that use a developmental framework, such as the Early Start Denver Model (ESDM), evidence for this type of intervention is currently insufficient because few studies have been published to date.
Less intensive interventions focusing on providing parent training for bolstering social communication skills and managing challenging behaviors have been associated in individual studies with short-term gains in social communication and language use. The current evidence base for such treatment remains insufficient, with current research lacking consistency in interventions and outcomes assessed.
Although all of the studies of social skills interventions reported some positive results, most have not included objective observations of the extent to which improvements in social skills generalize and are maintained within everyday peer interactions. Strength of evidence is insufficient to assess effects of social skills training on core autism outcomes for older children or play-and interaction-based approaches for younger children.
In summary, while there is some evidence to support the premise that EIBI promotes gains in cognitive function, language skills, and adaptive behavior in young children with autism, overall the quality and consistency of results of this research are weak. Weaknesses in research design and analysis coupled with inconsistent results lead to important questions about the benefit of an expensive and intensive intervention. There is a need for larger, RTC studies to clarify the uncertainty about the effectiveness of EIBI for ASD. Until better research is completed, EIBI does not meet the Primary Coverage Criteria for evidence of effectiveness.
The Agency for Healthcare Research and Quality published (AHRQ, 2011) an evaluation of therapies for children with ASD between the ages of 2-12 focusing on treatment outcomes. They noted only 2 RCT’s with only one rated as good quality. They concluded that: “Some behavioral and educational interventions that vary widely in terms of scope, target, and intensity have demonstrated effects, but the lack of consistent data limits our understanding of whether these interventions are linked to specific clinically meaningful changes in functioning. The needs for continuing improvements in methodologic rigor in the field and for larger multisite studies of existing interventions are substantial. Better characterization of children in these studies to target treatment plans is imperative.” Similarly, a recent Cochrane review (Reichow, 2012) of EIBI for ASD noted: “There is some evidence that EIBI is an effective behavioral treatment for some children with ASD. However, the current state of the evidence is limited because of the reliance on data from non-randomized studies (CCT’s) due to the lack of RCT’s. Additional studies using RCT research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD. The following clinical trial was identified from ClinicalTrials.gov: NCT00698997.
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through November 2019. The key identified literature is summarized below.
Reichow et al (2018) published an update of a 2012 Cochrane review of the evidence for the effectiveness of early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Effective outcomes included increased functional behaviors and skills, decreasing autism severity, and improving intelligence and communication skills for young children with ASD. Selection criteria were randomized control trials (RCTs), quasi-RCTs, and controlled clinical trials (CCTs) in which EIBI was compared to a no-treatment or treatment-as-usual control condition. The participants must have been less than six years of age at treatment onset and assigned to their study condition prior to commencing treatment. Five studies were identified (one RCT and four CCTs) with a total of 219 children: 116 children in the EIBI groups and 103 children in the generic, special education services groups. The age of the children ranged between 30.2 months and 42.5 months. Three of the five studies were conducted in the USA and two in the UK, with a treatment duration of 24 months to 36 months. All studies used a treatment-as-usual comparison group. The authors concluded that there was weak evidence that EIBI may be an effective behavioral treatment for some children with ASD. The authors reported that the strength of the evidence in the review was limited because the majority of the evidence came from small studies that were not of the optimum design. Due to the inclusion of non-randomized studies, the overall quality of evidence was rated as 'low' or 'very low' using the GRADE system. It is important that providers of EIBI are aware of the current evidence and use clinical decision-making guidelines, such as seeking the family’s input and drawing upon prior clinical experience, when making recommendations to clients on the use EIBI. Additional studies using rigorous research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD.
The Agency for Healthcare Research and Quality (2017) published an update of a 2011 comparative effectiveness review on the effectiveness and safety of interventions targeting sensory challenges in children with autism spectrum disorder (ASD). Studies included in the review were those comparing interventions incorporating sensory-focused modalities with alternative treatments or no treatment. Studies had to include at least 10 children with ASD ages 2–12 years. Data was summarized qualitatively because of the heterogeneity of the data. Strength of evidence was also assessed. 24 unique comparative studies (17 newly published studies and 7 studies addressed in our 2011 review of therapies for children with ASD) were identified and included 20 randomized controlled trials (RCTs), 1 nonrandomized trial, and 3 retrospective cohort studies (3 low, 10 moderate, and 11 high risk of bias [ROB]). The review concluded that some interventions targeting sensory challenges may produce modest short-term (<6 months) improvements, primarily in sensory-related outcomes and outcomes related to ASD symptom severity; however, the evidence base for any category of intervention is small, and durability of effects beyond the immediate intervention period is unclear. Sensory integration–based approaches improved outcomes related to sensory challenges (low SOE) and motor skills (low SOE), and massage improved sensory responses (low SOE) and ASD symptoms (low SOE). Environmental enrichment improved nonverbal cognitive skills (low SOE). Auditory integration–based approaches did not improve language outcomes (low SOE). Some positive effects were associated with other approaches studied (music therapy, weighted blankets), but findings in these small studies were not consistent (insufficient SOE). Data on longer term results are lacking, as are data on characteristics that modify outcomes, effectiveness of interventions across environments or contexts, and components of interventions that may drive effects. In sum, while some therapies may hold promise and warrant further study, substantial needs exist for continuing improvements in methodologic rigor in the field.
Touzet et al (2017) published an article describing a randomised controlled trial on the impact of the Early Start Denver Model on the cognitive level of children with autism spectrum disorder (ASD). The study was a multicenter (4 centers in France, 1 center in Switzerland and 1 center in Belgium), randomized, controlled, single blind trial using a modified Zelen design. Children aged 15-36 months, diagnosed with ASD and with a developmental quotient (DQ) of 30 or above on the Mullen Scale of Early Learning (MSEL) were included. Expected enrollment is 180 children (120 in the control and 60 in the intervention group). The experimental group will receive 12 hours per week ESDM by trained therapists 10 hours per week in the centre and 2 hours in the toddlers' natural environment (alternating between the therapist and the parent). The control group will receive care available in the community. The primary outcome will be the change in cognitive level measured with the DQ scored at 2 years. Secondary outcomes will include change in autism symptoms, behavioral adaptation, communicative and productive language level, sensory profile and parents' quality of life. The primary analysis will use the intention-to-treat principle. As of April 2019, this clinical trial (NCT02608333) was still recruiting with an estimated completion date of September 30, 2021.
Mohammadzaheri et al (2015) published the results of a randomized control trial that compared two intervention conditions, a naturalistic approach, Pivotal Response Treatment (PRT) with a structured ABA approach on disruptive behavior during language intervention in the public schools. A Randomized Clinical Trial (RCT) design was used with the two groups of children that were matched according to age, sex and mean length of utterance. Thirty elementary school children (18 boys and 12 girls), ages 6 to 11 years old, participated in this study. Each child was diagnosed with autism by a child psychiatrist according to the DSM-IV-TR (American Psychiatric Association, 2000) and was referred the to the Hamaden University of Medical Sciences and Health Services in Iran for autism intervention. The data showed that the children demonstrated significantly lower levels of disruptive behavior with the PRT method of treatment.
Pickles et al (2016) published the results of a long-term follow-up of a randomized controlled trial on parent-mediated social communication therapy for young children with autism. This study was a follow-up of the Preschool Autism Communication Trial (PACT) to investigate whether the PACT intervention had a long-term effect on autism symptoms and continued effects on parent and child social interaction. PACT was a randomized controlled trial of a parent-mediated social communication intervention for children aged 2-4 years with core autism. Follow-up ascertainment was done at three specialized clinical centers in the UK (London, Manchester, and Newcastle) at a median of 5.75 years from the original trial endpoint. The main blinded outcomes were the comparative severity score (CSS) from the Autism Diagnostic Observation Schedule (ADOS), the Dyadic Communication Assessment Measure (DCMA) of the proportion of child initiations when interacting with the parent, and an expressive-receptive language composite. All analyses followed the intention-to-treat principle. PACT is registered with the ISRCTN registry, number ISRCTN58133827. 121 (80%) of the 152 trial participants were traced and consented to be assessed between July 2013, and September 2014. Mean age at follow-up was 10.5 years. The authors purported that the results were the first evidence to show long-term symptom reduction after a randomized controlled trial of early intervention in autism spectrum disorder. They support the clinical value of the PACT intervention and its implications on developmental theory.
2021 Update
Policy review completed with a literature search using the MEDLINE database through October 2021. No new literature was identified that would prompt a change in the coverage statement.
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through October 2022. No new literature was identified that would prompt a change in the coverage statement.
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through October 2023. No new literature was identified that would prompt a change in the coverage statement.
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through November 2024. No new literature was identified that would prompt a change in the coverage statement.
2025 Update
Annual policy review completed with a literature search using the MEDLINE database through November 2025. No new literature was identified that would prompt a change in the coverage statement. |
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Agency for Healthcare Research and Quality (AHRQ)(2017) Interventions Targeting Sensory Challenges in Children With Autism Spectrum Disorder—An Update AHRQ Pub No 17-EHC004-EF May 2017 Agency for Healthcare Research and Quality (AHRQ).(2011) Therapies for children with autism specrum disorders: a review of the research for parents and caregivers. AHRQ Pub. No. 11-EHC029-A. June 2011. Accessed at www.ahrq.gov. American Psychiatric Association(2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM®-5) Arlington, VA: American Psychiatric Publishing. Autism Speaks.(2018) Autism and Health. https://www.autismspeaks.org/sites/default/files/docs/facts_and_figures_report_final_v3.pdf. Bassett K, Green CJ, Kazanjian A.(2000) Autism and Lovaas treatment: A Systematic review of effectiveness evidence. Prepared for the British Columbia Office of Health Technology Assessment, Vancouver, Canada. .Retrieved 27 July 2008 from chspr.ubc.ca. Bishop-Fitzpatrick L, Minshew NJ, Eack SM(2013) systematic review of psychosocial interventions for adults with autism spectrum disorders. J Autism Dev Disord. Mar 2013; 43(3): 687-94. PMID 22825929 Dawson G, Rogers S, Munson J, et al.(2010) Randomized, controlled trial of an Intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. 2010;125(1):e17-e23. Lovaas OI.(1987) Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol.1987;55(1):3-9. McEachin JJ, Smith T, Lovaas Ol.(1993) Long-term outcome for children with autism who received early intensive behavioral treatment. Am J Ment Retard. 1993;97(4):359-391. Mohammadzaheri F, Koegel LK, Rezaei M, Bakhshi E(2015) A Randomized Clinical Trial Comparison Between Pivotal Response Treatment (PRT) and Adult-Driven Applied Behavior Analysis (ABA) Intervention on Disruptive Behaviors in Public School Children with Autism J Autism Dev Disord 2015 Sep; 45(9): 2899–2907 PMID: 25953148 Myers, SM, Johnson CP.(2007) Management of children with autism spectrum disorders. Pediatrics. 2007; 120(5):1162-1182. National Institute for Health and Care Excellence.(2022) Autism. Recognition, referral diagnosis and management of adults on the autism spectrum. National clinical guideline number 142. 2012. https://www.nice.org.uk/guidance/cg142/evidence/full-guideline-pdf-186587677. Pickles A, Le Couteur A, Leadbitter K, Salomone E, Cole-Fletcher R, Tobin H, Gammer I, Lowry J, Vamvakas G, Byford S, Aldred C, Slonims V, McConachie H, Howlin P, Parr JR, Charman T, Green J(2016) Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomised controlled trial Lancet 2016;388(10059):2501 Epub 2016 Oct 25 Institute of Psychiatry, Psychology and Neuroscience, Kings College London, UK PMID 27793431 Reichow B, Barton EE, Boyed BA, et al(2018) Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD) Cochrane Database Syst Rev 2018 May 9 Reichow B, Barton EE, Boyed BA, et al.(2012) Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012 Oct 17;10:CD009260. Rice C.(2006) Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm. Sallows GO, Graupner TD.(2005) ntensive behavioral treatment for children with Autism: four-year outcome and predictors. Am J Ment Retard, 2005;110(6):417-438. Shea V.(2004) A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism, 2004;8(4):349-367. Shea V.(2004) A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism, 2004;8(4):349-367. The American Psychiatric Assoc.(2000) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: Touzet S, Occelli P, Schröder C, Manificat S et al. IDEA Study Group. (2017) Impact of the Early Start Denver Model on the cognitive level of children with autism spectrum disorder: study protocol for a randomised controlled trial using a two-stage Zelen design BMJ Open 2017 Mar 27;7(3): e014730 doi: 101136/bmjopen-2016-014730 PMID: 28348195 Warren Z, Veenstra-VanderWeele J, Stone W, et al.(2011) Effective Health Care. Therapies for Children with Autism Spectrum Disorders. Executive Summary. Comparative Effectiveness Review No. 26. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm |
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