BlueCross BlueShield of Tennessee Medical Policy Manual

Applied Behavioral Analysis (ABA) Therapy

Does not apply to BlueCare.

DESCRIPTION

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). Challenging behaviors include, but are not limited to aggression, violence, destructiveness, self-injury (scratching, biting, head-banging), and self-stimulatory behavior which is repetitive and ritualistic (rocking, pacing, jumping up and down, gazing, lining up objects). Critical adaptive behaviors include, but may not be limited to rudimentary communication skills, eating and toilet training.

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 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 may incorporate different approaches, modalities and techniques.  Although existing on a continuum, these approaches can be generally categorized in two treatment models: Focused or Comprehensive ABA.

Focused ABA refers to treatment provided directly to the client for a limited number of behavioral targets. Focused ABA plans are appropriate for individuals who need treatment only for a limited number of key functional skills (e.g., self-care skills, sleep hygiene, safety skills) or have such acute problem behavior that its treatment should be the priority (e.g., self-injury, aggression, threats, pica, elopement, feeding disorders).

Comprehensive ABA refers to treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypy (repetitive behavior) are also addressed in comprehensive treatment sessions. Initially, this treatment model can involve 1:1 staffing and gradually include small-group formats. As the client progresses and meets established criteria for participation in larger or different settings, such as school and community groups participation should be provided. Comprehensive treatment may also be the appropriate approach for older individuals diagnosed with ASD. Training family members and other caregivers to manage problem behavior and to interact with the individual with ASD in a therapeutic manner is a critical component of any successful treatment plan.

Providers must use the following forms:

Behavior Health Authorization Request Forms (found on http://www.bcbst.com/providers/forms/index.page)

POLICY

MEDICAL APPROPRIATENESS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

Tenn. Code Ann. § 56-7-2367 (2018) 56-7-2367. Autism spectrum disorders.

IMPORTANT REMINDERS                                                                                                                      

ADDITIONAL INFORMATION 

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.

SOURCES 

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.

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.

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.

American Academy of Pediatrics. (2015, October). Early screening of autism spectrum disorder: recommendations for practice and research. Retrieved November 29, 2018 from http://pediatrics.aappublications.org.

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.

Behavior Analyst Certification Board. (2014).Applied behavior analysis treatment of autism spectrum disorder: practice guidelines for healthcare funders and managers. Retrieved December 10, 2018 from www.babc.com.

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)

Fernell, E., Hedvall,  Å., Westerlund, J., Höglund-Carlsson, L., Eriksson, M., Barnevik-Olsson, M., et al. (2011, November-December) Early intervention in 208 Swedish preschoolers with autism spectrum disorder. A prospective naturalistic study. Research in Developmental Disabilities, 32 (6), 2092-2101. Abstract retrieved December 4, 2018 from PubMed database.

Leaf, J., Leaf, J., Milne, C., Taubman, M., Oppenheim-Leaf, M., Torres, N., et al. (2017, February). An evaluation of a behaviorally based social skills group for individuals diagnosed with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47 (2), 243-259. Abstract retrieved December 4, 2018 from PubMed database.

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)

National Academies Press (2001). Educating children with autism: adaptive behaviors. Chapter 9. Washington DC: The National Academies of Sciences, Engineering, and Medicine.

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.

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.

National Institute for Health and Care Excellence. (2012, June) Autism spectrum disorder in adults: diagnosis and management. Clinical guideline. Retrieved December 7, 2018 from www.nice.org/uk.

National Institute for Health and Care Excellence. (2013, August) Autism spectrum disorder in under 19s: support and management. Clinical guideline. Retrieved December 7, 2018 from www.nice.org/uk.

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)

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)

Reichow, B., Hume, K., Barton, E., and Boyd, B. (2018, May) Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorder. Cochrane Database Systematic Review, 9 (5), CD009260. Abstract retrieved December 3, 2018 from PubMed database.

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)

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)

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)

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Options: 56-7-2367. Autism spectrum disorders. Retrieved November 29, 2018 from https://web.lexisnexis.com.

U. S. Preventative Services Task Force (2017, September) Final recommendation statement autism spectrum disorder in young children: screening. Retrieved November 29, 2018 from: https://www.uspreventiveservicestaskforce.org.

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)

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, December, last update search November 2018). Applied behavior analysis-based interventions for autism spectrum disorder. Retrieved November 29, 2018 from www.Hayesinc.com/subscribers. (141 articles and/or guidelines reviewed)

Wong, C., Odom, S., Hume, K., Cox, A., Fetting, A., Kucharczyk, S., et al. (2014) Evidence-based practices for children, youth, and young adults with autism spectrum disorder. Chapel Hill: The University of North Carolina. Retrieved December 7, 2018 from http://autismpdc.fpg.unc.edu.

ORIGINAL EFFECTIVE DATE:  4/1/2002

MOST RECENT REVIEW DATE:  4/30/2019

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment. 

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