Description of Procedure or Service

Behavior analysis is the scientific study of the principles of learning and behavior, specifically about how behavior affects, and is affected by, past and current environmental events in conjunction with biological variables. Adaptive Behavioral Treatment (ABT) refers to the application of current, evidence-based specialized principles of the applied behavior analysis discipline by a provider, such as a licensed and certified behavior analyst, trained in this intervention. The intent of ABT is to effect meaningful changes, which are durable and generalizable, in socially significant behaviors in everyday settings. ABT focuses on treating behavior difficulties and shaping behavior patterns through environmental adaptations and consistent reinforcement and consequences across settings and situations.

BCBSNC will collaborate with providers to implement best practices and standardization of outcome measures into the Applied Behavior Analysis treatment plan.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your provider. 

Policy

BCBSNC will provide coverage for Adaptive Behavior Treatment when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

This medical policy relates only to benefits for Adaptive Behavior Treatment as covered under N.C.G.S. § 58-3-192.  Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this medical policy.

Coverage for services described in this medical policy may be subject to prior authorization by Blue Cross Blue Shield of North Carolina or its designee.

Provider qualifications regarding licensure and board certification may vary according to member benefit design and the state in which the member receives services. Please consult the Member Benefit Booklet regarding coverage of services rendered by providers outside the State of North Carolina.

When Adaptive Behavioral Treatment is covered

Criteria to Initiate Care

Applied Behavior Analysis (ABA) may be considered medically necessary when all of the following criteria are met:

1. There is a confirmed diagnosis of autism spectrum disorder (ASD); (ICD-10-CM Diagnosis Codes F84.0) based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice and the following must be provided:
   
   
   1. Initial requests must submit a complete diagnostic evaluation (e.g., Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview (ADI-R), Parent Evaluation Developmental Stages (PEDS), or Brigance Diagnostic Inventory of Early Development II)
   2. Documented ASD diagnosis in the individualized treatment plan which includes date of diagnosis and name and credentials of the person who made the diagnosis
2. Administration of a validated skill acquisition assessment that measures the individual’s functioning in the domains included in the diagnostic criteria for ASD in the DSM-5-TR as applicable to the individual and their individualized treatment plan/plan of care: social communication and social interaction; and restricted, repetitive patterns of behavior, interests, or activities|
   
   
   1. The assessment must be administered by a Board-Certified Behavior Analyst (BCBA), Licensed Behavior Analyst (LBA), or a licensed mental health clinician who has documented training ABA
   2. Standardized score tables and/or grids/figures must be provided, when applicable
   3. The assessment must have been administered within 60 days of the authorization start date
   4. The results identify the following:
      
      
      1. The target behavior or skill is 1 standard deviation or more below the mean, or
      2. Represents a behavior that poses significant threat of harm to the recipient or others
      3. Correspond with the content of the skill development and behavior reduction goal(s) within the submitted treatment plan
3. An individualized treatment plan that aligns with the results of the validated assessments and meets all of the following criteria:
   
   
   1. A review of the member’s complete developmental history, as well as ongoing collaboration and coordination with existing providers, as applicable.
   2. Individualized treatment goals objectively measurable within a specified time frame, attainable in relation to member’s prognosis and directly related to the core symptoms of ASD as defined by the DSM. The following criteria must be met:
       
      1. Treatment goals must be medically necessary and directly relate to the core symptoms of ASD as defined by the DSM
         
         
         1. Treatment plan goals requested are not more appropriately conducted by the following disciplines: Counseling/Mental Health services, Speech therapy, Occupational therapy, Vocational rehabilitation, Academic/Educational services, Feeding therapy
             
      2. Objective measures of baseline levels are recorded and quantifiable criteria for progress are established
          
   3. Documentation of parental/caregiver involvement and measurable parental/caregiver goals pertaining to learning behavioral principles of ABA and applicability of these behavioral interventions across settings
      
      
      1. Parental/caregiver goals must be objectively measurable and include objective baseline and mastery criteria
          
   4. A Behavior Support Plan, if appropriate, that contains the following:
      
      
      1. Operational, behavioral definition of the target behavior excesses and deficits, prevention and intervention strategies, schedules of reinforcement, and functional alternative responses
          
   5. Measurable criteria for completing treatment, with projected plan for continued care after discharge from ABA.
   6. Interventions emphasizing generalization of skills and focus on the development of spontaneous social communication, adaptive skills, and appropriate behaviors
   7. The number of service hours requested is justified by level impairment calculated by the behavioral assessment, length of treatment history, and severity of symptoms
   8. Documentation that ABA treatment will be delivered or supervised by an ABA credentialed professional
       
4. The recipient is medically stable and does not require 24-hour medical/nursing monitoring or procedures provided in a hospital level of care.

Criteria for Continued Care

Continuation of Applied Behavior Analysis (ABA) may be considered medically necessary when: (1) all of the criteria from documentation to initiate care section above are currently met and (2) all of the following criteria are met:

1. Validated skill acquisition assessments, treatment plans, and clinical documentation are current and completed at a minimum every six months; within 60 days of submission date.
2. As determined by validated skill acquisition assessment tools, the eligible recipient still cannot participate at an age-appropriate level in home, or community activities because of the presence of behavioral excess and/or the absence of functional skills that interfere with participation in these activities, and the target behaviors or skill deficits identified for ABA intervention meet one or more of the following:
   
   
   1. The target behavior or skill is one (1) standard deviation or more below the mean
   2. Represents a behavior that poses significant threat of harm to the recipient or others
       
3. Evaluation of progress, including data on targeted symptoms and behaviors is collected by direct therapy providers. The BCBA evaluates the data from all sessions and summarizes progress on each targeted symptom and behavior at least once every six (6) months. Evaluations must include the following elements:
   
   
   1. Progress is assessed and documented for each targeted symptom and behavior, including progress toward the defined goals and including the same models of measurement that were utilized for baseline measurements of specific symptoms and behaviors
   2. When goals have been achieved, either new goals should be identified or the treatment plan should be revised to include a transition to less intensive interventions
   3. When there has been inadequate progress or no progress demonstrated within a six (6) month period, or specific goals have not been achieved within the estimated timeframes, there should be an assessment of the reasons for the lack of progress or goals being unmet and treatment interventions should be modified or changed in order to attempt to achieve adequate progress
      
      
      1. If progress towards treatment goals is not being demonstrated, there must be evidence that the treatment plan is being adjusted
          
4. There is a clearly defined, measurable, individualized, and realistic titration plan that includes a plan for fading services across all settings and environments in which treatment is being or will be provided.
5. Updated individualized discharge criteria that are clearly defined, measurable, realistic, and are directly related to the symptoms of ASD and their effects as defined by the DSM-5-TR indicating the point at which services are appropriate for discontinuation and/or transfer to alternative or less intrusive levels of care.
6. The number of service hours is justified by the level of impairment calculated by the severity of symptoms, behavioral assessment(s), length of treatment history, and response to intervention
7. When an increase in treatment intensity is requested, all the following should be documented in the treatment plan:
   
   
   1. Evidence and quantitative data demonstrating how the increase in treatment intensity will improve outcome
   2. Clinical rationale related to the increase in treatment intensity
   3. Documentation related to how the increase in treatment intensity will be utilized
       
8. Caregivers demonstrate continued commitment to participation in the treatment plan and demonstrate the ability to apply those skills in naturalized settings as documented by measurable caregiver progress in the treatment plan
   
   
   1. In the absence of successful caregiver involvement, provider should identify appropriate alternative plan to promote the member’s ability to generalize skills in naturalized settings
       
9. The gains made toward developmental norms and behavior goals cannot be maintained if care is reduced
10. Behavior issues are not exacerbated by the treatment process
11. The recipient has the required cognitive capacity to benefit from the care provided and to retain and generalize treatment gains

Treatment Plan Preparation/Evaluation

Treatment plan preparation/evaluation (97151) up to 8 hours or 32 units annually are considered medical necessary. Documentation of medical necessity for over 32 units will be required.

When Adaptive Behavioral Treatment is not covered

1. Adaptive Behavioral Treatment is considered not medically necessary when the criteria outlined above are not met
2. Applied behavior analysis for diagnoses other than autism spectrum disorder
3. Services administered in a school/education setting (includes all types of educational settings)
4. Activities primarily of an educational nature or provided to access a school curriculum
5. Respite, shadow, or companion services
6. Services provided simultaneously with other medical services such as occupational therapy, speech and language therapy, physical therapy, and psychotherapy
7. Activities are not better described as another therapeutic service or outside the scope of practice of ABA (e.g., speech language therapy, occupational therapy, physical therapy, counseling, psychotherapy, etc.), even if the provider has expertise in the provision of ABA
8. ABA services delivered by multiple ABA provider organizations/agencies/companies during the same authorization period

Criteria for Discharge from Care

Continuation of Applied Behavior Analysis (ABA) is considered not medically necessary in any of the following circumstances:

1. The recipient shows improvement from baseline in targeted skill deficits and problematic behaviors such that goals are achieved or maximum benefit has been reached
2. Caregivers have refused treatment recommendations.
3. Behavioral issues are exacerbated by the treatment.
4. Recipient is unlikely to continue to benefit or maintain gains from continued care.
5. The client does not demonstrate progress towards goals for successive authorization periods
6. Parent(s) (or guardians) have not participated in treatment for successive authorization periods

Definitions

Comprehensive Intervention: Services are provided for multiple targets across most or all developmental domains. Comprehensive interventions may close the gap between a recipient’s level of functioning and that of a typically developing peer.

Focused Intervention: Services are directed to a more limited set of problematic behaviors or skills deficits in areas such as self-care, social interaction, communication and personal safety. Focused services introduce and strengthen more adaptive behaviors in order to address specific challenges that are problematic for the recipient.

Functional behavior assessment (FBA): A functional assessment that is a rigorous method of gathering information about adaptive functioning and dysfunctional behaviors. The underlying theory of FBA is that most problem behaviors serve some type of an adaptive function reinforced by consequences. FBA is used in both designing a behavioral program for maximum effectiveness and guides development of an individualized treatment plan.

Adaptive Behavioral Treatments: Behavioral and developmental interventions that (1) systematically adapt or alter instructional and environmental factors, (2) directly teach new skills and behaviors that promote learning, communication, social interaction, and self-care through shaping, modeling, and other empirically-valid methods, and/or (3) change the consequences of behavior to increase adaptive behavior and decrease maladaptive behavior, which have been shown to be clinically effective through research published in peer reviewed scientific journals and based upon randomized, quasi-experimental, or single subject designs.  

Policy Guidelines

This policy was developed after extensive review of the available literature on intensive behavioral therapies for treatment of autism. A multidisciplinary committee of health care professionals whose scope of practice includes treatment of autism developed and approved the guidelines based on this review. The guidelines were developed in consultation with experts in the treatment of autism from major research and treatment centers like the University of North Carolina at Chapel Hill, Duke University, and the Autism Society of North Carolina. The guidelines rely heavily on known best practices in the treatment of developmental disorders including the requirement for a complete assessment utilizing validated tools and standardized developmental norms; symptom focused interventions; caregiver participation and measurable goals.

Provider Qualifications

I. Providers performing services within North Carolina

Adaptive Behavioral Treatment must be provided or supervised by one of the following licensed professionals:

1. Licensed Psychologist or Psychological Associate
2. Licensed Psychiatrist or Developmental Pediatrician
3. Licensed Speech and Language Pathologist
4. Licensed Occupational Therapist
5. Licensed Clinical Social Worker
6. Licensed Clinical Mental Health Counselor
7. Licensed Marriage and Family Therapist.
8. Board Certified Behavioral Analyst.

Adaptive behavior treatment may be provided by an unlicensed paraprofessional who meets the following requirements:

1. Is supervised by one of the licensed professionals listed in #1-7 above; AND
2. Is at least 18 years of age; AND
3. Meets either Option A) or B) below:
   
   
   1. Is currently certified by the Behavior Analyst Certification Board with one of the following certifications:
      
      
      1. Board Certified Behavior Analyst – Doctoral
      2. Board Certified Behavior Analyst
      3. Board Certified Assistant Behavior Analyst
      4.  Registered Behavior Technician
          
   2. As attested to by the supervising licensed professional, meets all the following criteria:
      
      
      1. Has documented training in all the following topics:
         
         
         • North Carolina’s legal and ethical requirements for maintaining confidentiality; and
         • Exceptions to confidentiality in North Carolina including mandated reporting of suspected abuse or neglect; and
         • Professional conduct and ethics of the licensed supervisor’s profession; AND
            
      2. Has documented coursework, didactic training, and/or assigned and verified reading pertinent to Autism Spectrum Disorder and to the ABT being delivered (or the licensed supervisor has documented why this was not considered necessary); AND
      3.  Before working independently with the actual client, has documented mastery of the techniques in the empirically-supported ABT plan to be used (or the licensed supervisor has documented why this was not considered necessary); AND
      4. Is receiving documented ongoing supervision by the licensed professional during any period in which the unlicensed individual provides ABT services.  

Additional requirements for providers within North Carolina:
Assessments and interventions for adaptive behavior treatment must be ordered by a licensed physician or licensed psychologist.

All services performed must be within the scope of license and ethical boundaries of the licensed professional to be eligible for reimbursement.

Licensed providers must attest to expertise in treatment of autism spectrum disorders. Training in specific evidence-based modalities should include one or more of the following: a) accredited collegeor university-based courses; b) workshops, seminars, conferences – including online; c) supervised experience with ASD; d) work experience with ASD; e) other (e.g. worked as a supervisor of ASD treatment; published a peer-reviewed article about ASD treatment).

II. Providers performing services outside North Carolina

Note: these criteria apply only to members insured through ASO client groups opting into NC mandated autism benefits. Please refer to the Member’s Benefit Booklet for availability of benefits.

Provider qualifications regarding licensure and board certification may vary according to member benefit design and the state in which the member receives services. Please consult the Member Benefit Booklet regarding coverage of services rendered by providers outside the State of North Carolina.

Adaptive Behavioral Treatment must be provided or supervised by one of the following licensed professionals:

1. Licensed Psychologist or Psychological Associate 
2. Licensed Psychiatrist or Developmental Pediatrician 
3. Licensed Speech and Language Pathologist 
4. Licensed Occupational Therapist 
5. Licensed Clinical Social Worker 
6. Licensed Clinical Mental Health Counselor 
7. Licensed Marriage and Family Therapist. 
8. Licensed Behavior Analyst *
   
   ∗ In states where licensing is not available for Behavior Analysts, treatment may be provided by an unlicensed paraprofessional who meets the following requirement:
    
   1. Meets all supervisory requirements of local state licensing boards and local institutional privileging, as applicable; AND 
   2. Is at least 18 years of age; AND 
   3. Is currently certified by the Behavior Analyst Certification Board with one of the following certifications:
       
      • Board Certified Behavior Analyst—Doctoral 
      • Board Certified Behavior Analyst 
      • Board Certified Assistant Behavior Analyst 
      • Registered Behavior Technician AND 

Additional requirements for providers outside North Carolina:

1. Assessments and interventions for adaptive behavior treatment must be ordered by a licensed physician or licensed psychologist, in accordance with licensing and/or certification requirements in the state where the member receives treatment. 
2. All services performed must be within the scope of licensing and/or certification and ethical boundaries of the professional to be eligible for reimbursement.
3. Providers must attest to expertise in treatment of autism spectrum disorders. Training in specific evidence-based modalities should include one or more of the following: a) accredited college- or university-based courses; b) workshops, seminars, conferences – including online; c) supervised experience with ASD; d) work experience with ASD; e) other (e.g. worked as a supervisor of ASD treatment; published a peer-reviewed article about ASD treatment).

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes:  97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

Banda, D.R. & Grimmett, E. (2008).  Enhancing Social and Transition Behaviors of Persons with Autism through Activity Schedules: A Review. Education and Training in Developmental Disabilities, 2008, 43, 324-333.

Comparative efficacy of LEAP, TEACCH and non-model-specific special education programs for preschoolers with autism spectrum disorders. Boyd BA, Hume K, McBee MT, Alessandri M, Gutierrez A, Johnson L, Sperry L, Odom SL. J Autism Dev Disord. 2014 Feb;44(2):366-80.

D’Elia, L., Valeri, G., Sonnino, F., Fontana, I., Mammone, A., & Vicari, S. (2014).  A longitudinal study of the TEACCH program in different settings: The potential benefits of low intensity intervention in preschool children with autism spectrum disorder.  Journal of Autism and Developmental Disorders, 44, 615–626. 

Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125, e17–23.

Estes A, Munson J, Rogers S, Greenson J, Winter J, Dawson G (2015). Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder. Journal of the American Academy of Child and Adolescent Psychiatry. Jul;54(7):580-7.

General assembly of North Carolina. Session 2019. Senate bill 537. Licensing & HHS Amends & Rural Health Stable. https://www.ncleg.gov/Sessions/2019/Bills/Senate/PDF/S537v5.pdf

Hirasawa, N. Fujiwara, Y. Yamane, M. (2009). Physical arrangements and staff implementation of function based interventions in school and community settings. Japanese Journal of Special Education, 46, 435-446.

Howley, M. (2015).  Outcomes of structured teaching for children on the autism spectrum: does the research evidence neglect the bigger picture?  Journal of Research in Special Educational Needs, 15, 106-119. 

Lequia, J., Machalicek, W., & Rispoli, M.J. (2012).  Effects of activity schedules on challenging behavior exhibited in children with autism spectrum disorders: A systematic review.  Research in Autism Spectrum Disorders 6, 480–492.

Mandell D. S., Stahmer, A.C., Shin, S. Xie, M., Reisinger, E., & Marcus, S. C. (2013).  The role of treatment fidelity on outcomes during a randomized field trial of an autism intervention.  Autism, 17, 281–295.

McPheeters ML, Weitlauf A, Vehorn A, et al. Screening for Autism Spectrum Disorder in Young Children: A Systematic Evidence Review for the US Preventive Services Task Force: Evidence Synthesis No. 129 [AHRQ Publication No. 13-05185-EF-1]. Rockville, MD: Agency for Healthcare Research and Quality; 2016.

National Autism Center. (2009). National standards project findings and conclusions. Randolph, MA: Author.  

Odom, S., Hume, K., Boyd, B., & Stabel, A.  (2012). Moving beyond the intensive behavior treatment versus eclectic dichotomy: Evidence-based and individualized programs for learners with ASD.  Behavior Modification, 36, 270–297. 

Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 512–20.

Rogers, S. J. & Vismara, L. A. (2008). Evidence-based comprehensive treatments for early autism.  Journal of Clinical Child & Adolescent Psychology, 37, 8–38.

Stahmer, A., Schreibman, L., & Cunningham, A. (2011). Toward a technology of treatment individualization for young children with autism spectrum disorders.  Brain Research, 1380, 229–239.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R. (2015). Evidence-Based Practices for Children, Youth, and Young Adults with Autism Spectrum Disorder: A Comprehensive Review. Journal of Autism and Developmental Disorders, 45(7), 1951-1966. doi:10.1007/s10803-014-2351-z

Wong, C., Odom, S. L., Hume, K. Cox, A. W., Fettig, A., Kucharczyk, S., … Schultz, T. R. (2013). Evidence-based practices for children, youth, and young adults with autism spectrum disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R. (2015). Evidence-Based Practices for Children, Youth, and Young Adults with Autism Spectrum Disorder: A Comprehensive Review. Journal of Autism and Developmental Disorders, 45(7), 1951-1966. doi:10.1007/s10803-014-2351-z

Medical Director review – 1/2018

Specialty Matched Consultant Advisory Panel Review 6/2020

Specialty Matched Consultant Advisory Panel Review 6/2021

Medical Director review 6/2021

Specialty Matched Consultant Advisory Panel Review 6/2022

Medical Director review 6/2022

Medical Director review 8/2022

Specialty Matched Consultant Advisory Panel Review 6/2023

Medical Director review 6/2023

Specialty Matched Consultant Advisory Panel Review 6/2024

Medical Director review 6/2024

Specialty Matched Consultant Advisory Panel Review 4/2025

Medical Director review 4/2025

Policy Implementation/Update Information

4/29/16 New policy developed. BCBSNC will provide coverage for Adaptive Behavior Treatment when it is determined to be medically necessary because the medical criteria and guidelines outlined in the policy are met. Notification given 4/29/16 for effective date 7/1/16. (an)

8/30/16 Specialty Matched Consultant Advisory Panel Review 7/27/2016. No change to policy. (an)

7/28/17 Specialty Matched Consultant Advisory Panel Review 6/28/2017. No change to policy statement. (an)

1/26/18 Statement added to Benefits Application section: “Provider qualifications regarding licensure and board certification may vary according to member benefit design and the state in which the member receives services. Please consult the Member Benefit Booklet regarding coverage of services rendered by providers outside the State of North Carolina.” Policy Guidelines sections reformatted to clarify qualifications for providers inside and outside North Carolina. (an)

7/27/18 Specialty Matched Consultant Advisory Panel Review 6/27/2018. No change to policy statement. (an)

12/31/18 New codes for 2019 added to the Billing/Coding section: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158. Deleted codes: 0359T, 0360T, 0361T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0374T. (an)

7/30/19 Specialty Matched Consultant Advisory Panel Review 7/10/2019. No change to policy statement. (eel)

7/28/2020 Specialty Matched Consultant Advisory Panel Review 6/2020. Updated Policy Guidelines section, Provider Qualifications I and II: Changed title of Licensed Professional Counselor to Licensed Clinical Mental Health Counselor per NC Bill 537. Reference added. No change to policy statement. (bb)

7/13/2021 Specialty Matched Consultant Advisory Panel Review 6/2021. References added. No change to policy statement. (bb)

10/1/21 Statement added to Policy Guidelines section Provider Qualifications, Providers performing services within North Carolina 8) Licensed Behavior Analyst. The General Assembly of North Carolina Session 2021, Senate Bill 103, Chapter 90 of the General Statues is amended by adding a new article (Article 43. Behavior Analyst Licensure. The newly established North Carolina Behavioral Analysis Board will issue a license to engage in the practice of behavior analyst if the applicant meets the qualifications set forth by the Board in accordance with G.S. 90-726.4(a) and provides satisfactory evidence to the Board that all criteria established are met. Update to Billing/Coding/Physician Documentation Information section for the number of number of units considered medically necessary. Notification given 10/1/2021 for effective date 1/1/2022 (tt)

7/12/22 Update made to When Covered section to remove following criteria: “There is an established and current (within 5 years) DSM-5 diagnosis of Autism Spectrum Disorder using one or more validated assessment tool (e.g., Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview (ADI-R), Childhood Autism Rating Scale (CARS), Social Communication Questionnaire (SCQ), Social Reciprocity Scale (SRS), Gilliam Autism Rating Scale (GARS);” Specialty Matched Consultant Advisory Panel Review 6/2022. Medical Director Review 6/2022. References added. (tt)

9/13/22 Added the following statement to When Covered Section: “There is an established DSM-5 diagnosis of Autism Spectrum Disorder diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism. Medical Director review 8/2022. Notification given 9/13/2022 for effective date 11/15/2022. (tt)

6/30/23 Specialty Matched Consultant Advisory Panel Review 6/2023. References added. No change to policy statement. Medical Director review 6/2023. (tt)

7/17/24 Specialty Matched Consultant Advisory Panel Review 6/2024. References added. No change to policy statement. Medical Director review 6/2024. (tt)

4/30/25 Description, policy guidelines, and references updated. Coverage criteria updated to reflect current standards care. Specialty Matched Consultant Advisory Panel Review 4/2025. Medical Director review 4/2025. Notification given 4/30/2025 for effective date 7/1/2025. (tt)