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UM Guidelines
Applied Behavioral Analysis - For BlueCare Use Only

Behavioral Health

BCBST last reviewed October 1, 2017*

 

Clinical Indications for Procedure

Applies to BlueCare Only.

Applied Behavior Analysis (ABA) therapy is appropriate as indicated by 1 or more of the following:

Evidence Summary

Background

Applied behavioral analysis (ABA) therapy is a structured and systematic approach to reduce the intensity, frequency and/or duration of challenging behaviors and increase the use of critical adaptive behaviors for those individuals who have a diagnosis of Autism Spectrum Disorder (ASD) Intellectual disability, and/or traumatic brain injury. Challenging behaviors can include, but are not limited to aggression, violence, destructiveness, self-injury (scratching, biting, head-banging), and self-stimulatory behavior which may be repetitive and ritualistic (rocking, pacing, jumping up and down, gazing, lining up objects). The member may need assistance with critical adaptive behaviors include, but may not be limited to rudimentary communication skills, eating and toilet training as well.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by impaired social communication and social interaction accompanied by atypical patterns of behavior and interest. ASD is differentiated from other developmental disorders by significant impairments in social interaction and communication, along with restrictive, repetitive, and stereotypical behaviors and activities. The conditions formerly called autism, Asperger syndrome, and pervasive developmental delay‒not otherwise specified were merged into a single diagnosis called ASD in 2013.

ABA therapy involves a systematic analysis of behavior by a qualified practitioner, utilizing careful observation in the child’s natural environment to identify challenging behaviors that are triggered by environmental factors. A treatment plan is developed and implemented that uses environmental modification, behavioral stimuli and consequences to produce socially significant improvements in critical adaptive behaviors and reduce the severity and frequency of challenging behaviors. Parental/caregiver involvement is essential to long-term treatment success.

ABA therapy programs may also be referred to as intensive behavioral intervention (IBI), early intensive behavioral intervention (EIBI), Lovaas therapy [also referred to as the University of California Los Angeles (UCLA) method], or Early Start Denver Model (ESDM).

Criteria

Since the 1980’s a growing evidence base suggests that behavioral interventions are associated with positive outcomes for children with ASD. However, it is generally agreed among practitioners and major professional societies that the evidence is at best low quality with wide variations in methodology, findings and philosophical bias making well defined conclusions difficult.  

Inconclusive or Non-Supportive Evidence

For Group Therapy Format; Telemedicine format (in compliance with TN State law); and Parent and/or caregiver support groups, Applied Behavioral Analysis (ABA) therapy is considered not medically necessary.

Applied Behavioral Analysis (ABA) therapy interventions that include, but are not limited to, any of the following would be considered investigational:

References

  1. Agency for Healthcare Research and Quality. U. S. Department of Health and Human Services. (2014, August). Effective Health Care Program. Comparative Effectiveness Review, Number 137. Therapies for children with autism spectrum disorder: behavioral interventions update. Retrieved April 21, 2016 from http://effectivehealthcare.ahrq.gov.
  2. American Academy of Child and Adolescent Psychiatry. Committee on Quality Issues. (2014, February). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 53 (2), 237-257.
  3. American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (February, 2014). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Retrieved April 20, 2016 from the National Guideline Clearinghouse (NGC: 010489).
  4. American Academy of Pediatrics. (2012). Pediatrics®. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Retrieved April 21, 2016 from http://pediatrics.aappublications.org.
  5. American Psychiatric Association (2013, May). Diagnostic and statistical manual of mental disorders (DSM-5): autism spectrum disorder. Retrieved September 22, 2016 from: https://www.autismspeaks.org
  6. BlueCross BlueShield of Tennessee network physicians June – September 2017.
  7. Cincinnati Children’s Hospital Medical Center. (June, 2012). Best evidence statement (BESt). The use of video-based modeling in teaching daily living skills to children with autism. Retrieved April 20, 2016 from the National Guideline Clearinghouse (NGC: 9273).
  8. Cincinnati Children’s Hospital Medical Center. (February, 2013). Best evidence statement (BESt). Adding home based services to complement center based intervention for children with autism. Retrieved April 20, 2016 from the National Guideline Clearinghouse (NGC: 9777).
  9. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized control trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics, 125 (1), e17- e23. (Level 3 evidence)
  10. Lovaas, O. I. (1993). The development of a treatment-research project for developmentally disabled and autistic children. Journal of Applied Behavior Analysis, 26 (4), 617-630. (Level 4 evidence)
  11. National Academies Press (2001). Educating children with autism: adaptive behaviors. Chapter 9. Washington DC: The National Academies of Sciences, Engineering, and Medicine.
  12. National Autism Center (2009). National standards project: Phase 1. Addressing the needs for evidence based practice guidelines for autism spectrum disorder: findings and conclusions. Retrieved September 22, 2016 from: www.nationalautismcenter.org.
  13. National Autism Center (2015). National standards project: Phase 2. Addressing the needs for evidence based practice guidelines for autism spectrum disorder: findings and conclusions. Retrieved September 22, 2016 from: www.nationalautismcenter.org.
  14. Ospina, M. B., Selda, J. K., Clark, B., Karkhaneh, M., Hartling, L., Tjosvold, L., et al. (2008). Behavioural and developmental interventions for autism spectrum disorder: A clinical systematic review. PLoS One, 3 (11), 1-32.e3755. (Level 1 evidence)
  15. Reichow, B., & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA young autism project model. Journal of Autism and Developmental Disorders, 39 (1), 23-41. (Level 1 evidence)
  16. Serna, R. W., Lobo, H. E., Fleming, C. K., Fleming, R. K., Curtin, C., Foran, M. M., et al. (2015). Innovations in behavioral intervention preparation for paraprofessionals working with children with autism spectrum disorder. Journal of Special Education Technology, 30 (1), 1-12. (Level 5 evidence)
  17. Spreckley, M., & Boyd, R. (2009). Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: A systematic review and meta-analysis. The Journal of Pediatrics, 154 (3), 338-344. (Level 1 evidence)
  18. Technology Evaluation Center. (2015, March). Special report: Early intensive behavioral intervention based on applied behavior analysis among children with autism spectrum disorder. (Vol. 30, No. 1). Chicago: BlueCross BlueShield Association. (30 articles and/or guidelines reviewed)
  19. Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2367. Autism spectrum disorders. Retrieved September 22, 2016, 2016 from https://web.lexisnexis.com.
  20. U. S. Preventative Services Task Force ( 2016, February) Screening for autism spectrum disorder in young children. Retrieved September 22, 2016 from: National Guideline Clearinghouse (NGC#010905)
  21. Virues-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression and dose–response meta-analysis of multiple outcomes. Clinical Psychology Review (30) 387-399. (Level 2 evidence)
  22. Winifred S. Hayes, Inc. Medical Technology Directory. (2014, December, last update search November 2015). Applied behavior analysis-based interventions for autism spectrum disorder. Retrieved April 20, 2016 from www.Hayesinc.com/subscribers.  (130 articles and/or guidelines reviewed)
  23. TennCare Medical Necessity Guidelines Procedure: Applied Behavioral Analysis.  https://www.tn.gov/assets/entities/tenncare/attachments/apcard.pdf.