Medicaid

Applied Behavioral Analysis, BH 37

Table of Content Effective Date 12/2021
Purpose Keywords
Description & Definitions Next Review Date 6/2025
Criteria
Discharge Criteria
Coding Coverage Policy BH 37
Document History
References Version 4
Special Notes

All requests for authorization for the services described by this medical policy will be reviewed per
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines. These services may be
authorized under individual consideration for Medicaid members under the age of 21-years if the
services are judged to be medically necessary to correct or ameliorate the member’s condition.
Department of Medical Assistance Services (DMAS), Supplement B - EPSDT (Early and Periodic
Screening, Diagnosis and Treatment) Manual *.

Purpose:
This policy addresses Applied Behavioral Analysis

Description & Definitions:

Mental Health Services – App. D - Intensive Community Based Support – Youth p. 21 (05/15/2024)
“Applied Behavior Analysis” or “ABA” means the practice of behavior analysis as established by the Virginia Board of
Medicine in § 54.1-2900 as the design, implementation, and evaluation of environmental modifications using behavioral
stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct
observation, measurement, and functional analysis of the relationship between environment and behavior.

ABA services must include the following four characteristics:

• An objective assessment and analysis of the client’s condition by observing how the environment affects the
client’s behavior, as evidenced through appropriate data collection.
• Importance given to understanding the context of the behavior and the behavior’s value to the youth, the family,
and the community.
• Utilization of the principles and procedures of behavior analysis such that the client’s health, independence, and
quality of life are improved.
• Consistent, ongoing, objective assessment and data analysis to inform clinical decision-making.

The following required activities apply to ABA:

• An initial assessment for ABA consistent with the components required in the Comprehensive Needs Assessment
(see Chapter IV for requirements), documenting the youth's diagnosis/es and describing how service needs
match the level of care criteria must be completed at the start of services. The initial assessment must:
o be completed by the LBA, LABA or LMHP acting within the scope of practice. An assessment completed
by an LABA can only be used as an assessment for ABA and cannot be used as a Comprehensive

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o Needs Assessment for other services. Other qualified staff may assist with the completion of an
assessment
o be conducted in-person with the youth and the youth’s family/caregivers
o Include a functional assessment using validated tools completed by the LBA, LABA or LMHP acting within
the scope of practice.
• The LBA, LABA or LMHP must, at a minimum, observe the youth monthly. Assessments must be reviewed and
updated at least annually by the LBA, LABA or LMHP.

Family training related to the implementation of ABA shall be included. ABA may be provided in the home or community
settings where the targeted behaviors are likely to occur. ABA may also be provided in clinic settings. Limited services are
allowed in the school setting (see service limitations section). The setting must be justified in the ISP.

Refer to the Billing Guidance section for a list of approved Current Procedural Terminology (CPT) codes.

Criteria:
Mental Health Services – App. D - Intensive Community Based Support – Youth p. 24 (05/15/2024)

Applied Behavioral Analysis is considered medically necessary for all of the following:

• Treatment is for 1 or more of the following:

o Initial Care with all of the following:
 The youth must have a current psychiatric diagnosis as defined in the Diagnostic and Statistical
Manual of Mental Disorders (DSM) or have a provisional psychiatric diagnosis as developed by
an LMHP when no definitive diagnosis has been made
 The youth must meet criteria on a continuing or intermittent basis at least 2 or more of the
following:
• Non-verbal or limited functional communication and pragmatic language, unintelligible or
echolalic speech, impairment in receptive and/or expressive language
• Severe impairment in social interaction /social reasoning /social reciprocity/ and
interpersonal relatedness
• Frequent intense behavioral outbursts that are self-injurious or aggressive towards others
• Disruptive obsessive, repetitive, or ritualized behaviors
• Difficulty with sensory integration
 There is a family/caregiver available to participate in this intensive service.
o Continuation of services are considered medically necessary with all of the following:
 Within the past thirty (30) calendar days, the youth has continued to meet the admission criteria
for ABA as evidenced by at least 1 or more of the following:
• The youth’s symptoms/behaviors and functional impairment persist at a level of severity
adequate to meet admission criteria;
• The youth has manifested new symptoms that meet admission criteria and those have
been documented in the ISP;
• Progress toward identified ISP goal(s) is evident and has been documented based upon
the objectives defined for each goal, but not all of the treatment goal(s) have been
achieved.
 To consider approval for continued stay requests, documentation will be reviewed and should
demonstrate active treatment and care coordination through all of the following:
• An individualized ISP with evaluation and treatment objectives appropriate for this level of
care and type of intervention
• Progress toward objectives is being monitored as evidenced in the 30 calendar day ISP
review documentation
• The youth and family/caregiver are actively involved in treatment, or the provider has
documented active, persistent efforts that are appropriate to improve engagement
• The type, frequency and intensity of interventions are consistent with the ISP

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• The provider has developed an individualized discharge plan that includes specific plans
for appropriate follow-up care
o If youth does not meet criteria for continued treatment, ABA may still be authorized for up to an
additional 10 calendar days under any 1 or more of the following circumstances:
 There is no less intensive level of care in which the objectives can be safely accomplished
 The youth can achieve certain treatment objectives in the current level of care and achievement
of those objectives will enable the youth to be discharged directly to a less intensive community
service rather than to a more restrictive setting
 The youth is scheduled for discharge, but the youth requires services at discharge which are still
being coordinated and are not currently available.

In addition to the “Non-Reimbursable Activities for all Mental Health Services” section in Chapter IV of the DMAS
manual, the following service limitations apply:

• Services cannot be authorized concurrently with

o Intensive In-Home,
o Mental Health Skill Building,
o Psychosocial Rehabilitation,
o Partial Hospitalization Program,
o Assertive Community Treatment.
o Short-term service authorization overlaps are allowable as approved by the FFS service
authorization contractor or MCO during transitions from one service to another for care
coordination and continuity of care.
• The following shall not be covered under ABA:
o Services rendered primarily by a relative or guardian who is legally responsible for the youth's care.
o ABA may only be provided in the school setting when the purpose is for observation and
collaboration by the QHP related to behavior and skill acquisition (not direct therapy) and services
have been authorized by the school, parent and provider and included in the ISP. Additional
coverage for ABA in the school setting may be available under school health services. See the
Local Education Agency Manual for information.

Discharge Criteria:
Mental Health Services – App. D - Intensive Community Based Support – Youth p. 25 (05/15/2024)

The provider must terminate ABA if the service is no longer medically necessary. The service is no longer deemed
medically necessary if 1 or more of the following criteria is met within a thirty day time period:

• No meaningful or measurable improvement has been documented in the youth’s behavior(s) despite receiving
services according to the ISP; there is reasonable expectation that the family and /or caregiver are adequately
trained and able to manage the youth’s behavior; and termination of the current level of services would not result
in further deterioration or the recurrence of the signs and symptoms that necessitated treatment.
• Treatment is making the symptoms persistently worse or the youth is not medically stable for ABA to be effective
• The youth has achieved adequate stabilization of the challenging behavior and less intensive modes of therapy
are appropriate
• The youth demonstrates an inability to maintain long-term gains from the proposed ISP
• The family and/or caregiver refuses or is unable to participate meaningfully in the behavior treatment plan.

If there is a lapse in service for more than 31 consecutive calendar days, the provider must discharge the youth
from services and notify the FFS Contractor or MCO. If services resume after a break of more than 31
consecutive calendar days, a new service authorization request including a new assessment and ISP must be
submitted to the FFS Contractor or MCO.

Behavioral Health 37 Page 3 of 6

Coding:
Medically necessary with criteria:
Coding Description

97151 Behavior identification assessment, administered by a physician or other qualified health

care professional,
each 15 minutes of the physician's or other qualified health care professional's time face-to-
face with patient and/or guardian (s)/caregiver(s) administering assessments and
discussing findings and recommendations, and non-face-to-face analyzing past data,
scoring/interpreting the assessment, and preparing the report/treatment plan

97152 Behavior identification-supporting assessment, administered by one technician under the

direction of a
physician or other qualified health care professional, face-to-face with the patient, each 15
minutes

97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a
physician or other
qualified health care professional, face-to-face with one patient, each 15 minutes

97154 Group adaptive behavior treatment by protocol, administered by technician under the
direction of a physician
or other qualified health care professional, face-to-face with two or more patients, each 15
minutes

97155 Adaptive behavior treatment with protocol modification, administered by physician or other
qualified health
care professional, which may include simultaneous direction of technician, face-to-face with
one patient, each 15 minutes

97156 Family adaptive behavior treatment guidance, administered by physician or other qualified
health care
professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s),
each 15 minutes

97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or

other qualified
health care professional (without the patient present), face-to-face with multiple sets of
guardians/caregivers, each 15
minutes

97158 Group adaptive behavior treatment with protocol modification, administered by physician or
other qualified
health care professional, face-to-face with multiple patients, each 15 minutes

0362T Behavior identification supporting assessment, each 15 minutes of technicians' time face-
to-face with a
patient, requiring the following components: administration by the physician or other
qualified health care professional who
is on site; with the assistance of two or more technicians; for a patient who exhibits
destructive behavior; completion in an
environment that is customized to the patient's behavior.

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0373T Adaptive behavior treatment with protocol modification, each 15 minutes of technicians'
time face-to-face with
a patient, requiring the following components: administration by the physician or other
qualified health care professional who
is on site; with the assistance of two or more technicians; for a patient who exhibits
destructive behavior; completion in an
environment that is customized to the patient's behavior.

Considered Not Medically Necessary:

Coding Description

None

U.S. Food and Drug Administration (FDA) - approved only products only.

Document History:
Revised Dates:
• 2024: June – Updated Authorization Requirements, Description of Service, Exceptions & Limitations,
and Clinical Indications for Procedures to reflect updated language from DMAS manual revision dated
5/15/2024.
• 2023: July
• 2022: June

Reviewed Dates:
• 2022: September

Effective Date:
• December 2021

References:
Including but not limited to: Specialty Association Guidelines; Government Regulations; Winifred S. Hayes, Inc;
UpToDate; Literature Review; Specialty Advisors; National Coverage Determination (NCD); Local Coverage
Determination (LCD).

Behavioral health professionals are involved in the decision-making process for behavioral healthcare services.

Provider Manual Title: Mental Health Services. Revision Date: 5/15/2024 Appendix D: Intensive Community
Based Support - Youth. Retrieved 5.21.2024 https://vamedicaid.dmas.virginia.gov/sites/default/files/2024-
05/MHS%20-%20Appendix%20D%20%28updated%205.15.24%29_Final_0.pdf

Special Notes: *
This medical policy express Sentara Health Plan’s determination of medically necessity of services, and they are based
upon a review of currently available clinical information. These policies are used when no specific guidelines for coverage
are provided by the Department of Medical Assistance Services of Virginia (DMAS). Medical Policies may be superseded
by state Medicaid Plan guidelines. Medical policies are not a substitute for clinical judgment or for any prior authorization
requirements of the health plan. These policies are not an explanation of benefits.

Medical policies can be highly technical and complex and are provided here for informational purposes. These medical
policies are intended for use by health care professionals. The medical policies do not constitute medical advice or
medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice.
Sentara Health Plan members should discuss the information in the medical policies with their treating health care
professionals. Medical technology is constantly evolving and these medical policies are subject to change without notice,
although Sentara Health Plan will notify providers as required in advance of changes that could have a negative impact on
benefits.

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The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) covers services, products, or procedures for
children, if those items are determined to be medically necessary to “correct or ameliorate” (make better) a defect,
physical or mental illness, or condition (health problem) identified through routine medical screening or examination,
regardless of whether coverage for the same service or support is an optional or limited service under the state plan.
Children enrolled in the FAMIS Program are not eligible for all EPSDT treatment services. All requests for authorization
for the services described by this medical policy will be reviewed per EPSDT guidelines. These services may be
authorized under individual consideration for Medicaid members under the age of 21-years if the services are judged to by
medically necessary to correct or ameliorate the member’s condition. Department of Medical Assistance Services
(DMAS), Supplement B - EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Manual.

Keywords:
Applied Behavioral Analysis, ABA, Behavioral Health 37, BH, Autism, Intensive Community Based Support, youth,
spectrum disorder, Mental Health Services, Autistic Children

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