UM Guidelines
Evaluation / Assessment for Applied Behavior Analysis

Behavioral Health (BH)

BCBST last reviewed June 10, 2021*

Added Clinical Indications for Procedure:
   
 
  • Evaluation for Applied Behavioral Analysis (ABA) therapy is appropriate if ALL of the following are met[A]:
    • Diagnosis of Autism Spectrum Disorder using one or more validated assessment tools [e.g., DSM-5 severity levels rating, Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview (ADI-R), Childhood Autism Rating Scale (CARS), Gilliam Autism Rating Scale (GARS)]
    • Severity assessment of autism symptoms has been performed within the last 6 months (e.g., CARS, SMS-5 severity levels rating, Social Communication Questionnaire)
    • Evaluation for services will be done on a 1:1 basis between the qualified practitioner and the individual member and/or caregiver
    • There are severe challenging behavior(s) that are ANY ONE of the following:
      • Present a health or safety risk to self or others (e.g., self-injury, aggression toward others, destruction of property, stereotyped/repetitive behaviors, elopement, severe disruptive behavior)
      • Not generally seen as age or developmentally congruent (e.g., biting in a 2 to 4 yo, temper tantrums) that significantly interfere with home, school, or community activities
    • Behavior Health Authorization request Form (found on www.bcbst.com) completed and submitted (Evaluation prior not to exceed 15 hours; within 30 days)

Footnotes

[A] The assessment is required prior to receiving ABA Therapy.

References

  1. 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.
  2. 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).

 

 

 

 

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