Coverage Policy Manual
Policy #: 2011053
Category: Medicine
Initiated: July 2011
Last Review: December 2023
  Autism Spectrum Disorder in Children, Applied Behavioral Analysis
Description:
Autism spectrum disorder (ASD) is a complex, pervasive developmental disability characterized by variable social and communicative deficits with repetitive, restricted behaviors and for many, significant cognitive impairment. The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, Text Revision (DSM-V-TR) specifies autistic disorder, pervasive developmental disorder---not otherwise specified (PDD-NOS), and Asperger’s syndrome as included under the diagnosis of ASD. DSMV coalesces all of these diagnoses into Autism spectrum Disorder. The Center for Disease Control (CDC) estimates the prevalence of ASD as 1 out of every 68 children occurring in all ethnic, racial, and socioeconomic groups but 4-5 times more likely in boys than girls. A CDC report published in 2009, demonstrated that an average of 41% of ASD individuals met a definition of intellectual disability.
 
Applied Behavioral Analysis (ABA) is the behavioral treatment approach most commonly used with children with ASD. Techniques based on ABA include: Discrete Trial Training, Incidental Teaching, Pivotal Response Training, and Verbal Behavioral Intervention. ABA involves a structured environment, predictable routines, individualized treatment, transition and aftercare planning, and significant family involvement. ABA attempts to increase skills related to behavioral deficits and reduce behavioral excesses. Behavioral deficits may occur in the areas of communication, social and adaptive skills, but are possible in other areas as well. Examples of deficits may include: a lack of expressive language, inability to request items or actions, limited eye contact with others, and inability to engage in age-appropriate self-help skills such as tooth brushing or dressing. Examples of behavioral excesses may include, but are not limited to physical aggression, property destruction, elopement, self-stimulatory behavior, self-injurious behavior, and vocal stereotypy. Several discipline- specific intensive intervention programs have been developed and advocated for the treatment of autism (Lovaas therapy, Early Start Denver Model, and others).
 
ABA treatment is considered either comprehensive or focused based on the core symptoms targeted and the intensity of the intervention.
 
SERVICE INTENSITY CLASSIFICATION:
Comprehensive treatments range from 25 to 40 total hours of direct services weekly. Lucet Behavioral Health Services and Solutions will review each request on an individual basis for fidelity to medical necessity and approve total hours based on the member’s severity, intensity, frequency of symptoms and response to previous and current ABA treatment. Comprehensive treatment includes direct 1:1 ABA, caregiver training, supervision and treatment planning.
 
Comprehensive ABA treatment targets members whose treatment plans address deficits in all core symptoms of Autism. Appropriate examples of comprehensive treatment include early intensive behavioral intervention and treatment programs for older children with aberrant behaviors across multiple settings. This treatment level, which requires very substantial support, should initially occur in a structured setting with 1:1 staffing and should advance to the least restrictive environment appropriate for the member. This treatment is primarily directed to children ages 3 to 7 years old because Comprehensive ABA treatment has been shown to be most effective with this population in current medical literature. Caregiver training is an essential component of Comprehensive ABA treatment.
 
Focused treatments range from 10 to 25 total hours of direct services per week. Lucet Behavioral Health Services and Solutions will review each request on an individual basis for fidelity to medical necessity and approve total hours based on the member’s severity, intensity, frequency of symptoms and response to previous and current ABA treatment. This treatment may include individual services, group services and caregiver training.
 
Focused treatment typically targets a limited number of behavior goals requiring support of ABA treatment. Behavioral targets include marked deficits in social communication skills and restricted, repetitive behavior such as difficulties coping with change. In cases of specific aberrant and/or restricted, repetitive behaviors, attention to prioritization of skills is necessary to prevent and offset exacerbation of these behaviors, and to teach new skill sets. Identified aberrant behaviors should be addressed with specific procedures outlined in a Behavior Intervention Plan. Emphasis is placed on group work and caregiver training to assist the member in developing and enhancing his/her participation in family and community life, and developing appropriate adaptive, social or functional skills in the least restrictive environment.
 
Requested treatment hours outside of the range for Comprehensive or Focused treatment will require a specific clinical rationale.
 
Coding
 
Effective January 1, 2019, there are new CPT category I codes for applied behavioral analysis and are billed in 15 minute units. These services were previously billed with Category III codes in 30 minute or 1 hour units.  Coding instructions using the new CPT category I codes are listed below in the Policy/Coverage section.
 
*See additional detailed coding instructions in the Policy/Coverage section below
 
Related policy: 2011054 - Autism Spectrum Disorder Interventions other than Early Behavioral Intervention.
Policy/
Coverage:
For fully insured contracts, metallic contracts, and ASE/PSE contracts [subject to Ark act 23-99-418(d)(1)(A]), “coverage for autism is not subject to any limits on the number of visits an individual may make to an autism services provider.” “…applied behavior analysis, should have no limits on the number of visits for rehabilitative or habilitative services for autism.” Further AID “will not allow age limits for any service for the treatment of autism.” The visit and age limits below do not apply to those contracts subject to state law.
 
Effective January 2024
 
This policy applies only to those contracts that provide a benefit for Applied Behavioral Analysis in the treatment of Autism Spectrum Disorder.
 
Prior Approval of Services
 
Requests for coverage of ABA treatment will require Prior Approval (PA) for those contracts not subject to Arkansas Act 575 (e.g., Gold Card Law). Only federally chartered contracts (e.g., FEP and ERISA self-insured contracts) are exempt from this law.  All metallic contracts, commercial group and individual contracts, and state/local government/church self-insured groups have no requirement for PA.                   
 
Prior Approval should be done prior to services being provided. Lucet Behavioral Health Services and Solutions will administer Prior Approval and concurrent review of all ABA services for plans that have contracted with Lucet Behavioral Health Services and Solutions for management of their ABA services and are not subject to Act 575 as above. This policy only applies to members who have benefits through Arkansas Blue Cross and Blue Shield.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Applied behavioral analysis meets primary coverage criteria for individuals with a confirmed diagnosis of Autism Spectrum Disorder and a signed prescription from a licensed physician or licensed psychologist for ABA treatment in accordance with the ALL of the below parameters and guidelines:
 
    • ABA must be provided or supervised by a therapist certified by the nationally accredited Behavior Analyst Certification Board; AND  
    • For "Grandfathered" plans, ABA shall have an annual limitation of $50,000; OR  
    • For “Non-grandfathered” plans, ABA shall have limits as outlined in the policy and coding guidelines.
 
Parameters for Comprehensive Treatment*:
    • Children Age: 18 months up to 7 years of age, AND  
    • Duration: 3 years consecutively (e.g., child diagnosed at age 6 could have services through age 9), AND  
    • Intensity: minimum of 25 hours per week to maximum of 40 hours per week**of direct (line) services by behavioral technician or BCBA equivalent.
OR
 
Parameters for Focused Treatment*:
    • Children Age: 18 months to < 18 years, AND  
    • Duration: 36 months, AND  
    • Intensity: minimum of 10 hours per week to a maximum of 25 hours per week of direct (line) therapy services by a behavioral technician or BCBA equivalent.
 
*Comprehensive and Focused Treatment cannot be provided concurrently.
** In very limited situations where additional hours are determined to meet primary coverage criteria.
 
Lucet Behavioral Health Services and Solutions may authorize additional direct service hours as directed.
 
Treatments other than ABA do not fall under the scope of this policy; these services include but are not limited to treatments considered to be investigational/experimental, such as Cognitive Training; Auditory Integration Therapy; Facilitated Communication; Higashi Schools/Daily Life; Individual Support Program; LEAP; SPELL; Waldon; Hanen; Early Bird; Bright Start; Social Stories; Gentle Teaching; Response Teaching Curriculum and Developmental Intervention Model; Holding Therapy; Movement Therapy; Music Therapy; Pet Therapy; Psychoanalysis; Son-Rise Program; Scotopic Sensitivity Training; Sensory Integration Training; Neurotherapy (EEG biofeedback).
 
For all other diagnoses and indications, applied behavioral analysis does not meet primary coverage criteria and is not covered.
 
Requests for telehealth/telemedicine ABA services will be reviewed in accordance with current controlling health plan guidelines. The delivery of direct ABA services by telehealth/Telemedicine (e.g., 97152, 97153, 97154, 0372T, 0373T) are not covered. Telehealth/telemedicine for parent education (e.g., 97156 and 97157), direct supervision activities (e.g., 97155, 97158), and some assessment activities (97151) may be covered if allowed as an eligible telehealth/telemedicine service under the member benefit plan. These may account for only 50% of services (by code) unless extenuating circumstances are prior approved.
 
 
Policy Guidelines
 
ABCBS will require a multidisciplinary evaluation to include, at a minimum, formal testing and assessment by the following providers (who are not employed by the child’s educational institution):
 
    • A developmental pediatrician, pediatric neurologist, or child psychiatrist (or pediatrician with advanced training in focused developmental evaluations); and  
    • A licensed speech therapist with specialized training/experience in developmental pediatrics; and  
    • A licensed child psychologist with advanced training/experience in developmental pediatrics
 
Suggested testing by the multidisciplinary team normally includes:
 
    • Autism specific testing (ADOS, ADI-R CARS, etc.)
    • Hearing evaluation
    • Speech/language/communication assessment (Peabody Picture Vocabulary test {PPVT}, Expressive Vocabulary Test {EVT}, etc.
    • Developmental/cognitive testing (IQ, for instance Bayley Scales of Infant development, WECHSLER PRESCHOOL AND PRIMARY SCALE OF INTELLIGENCE, etc.)
    • Adaptive behavioral evaluation (VABS, ABAS)
    • Sensorimotor evaluation
    • Laboratory work as suggested by assessment (fragile x, serum lead, etc.)
 
For those plans subject to Act 196 of the General Assembly of the State of Arkansas enacted as of October 1, 2011, the coverage of Applied Behavioral Analysis (ABA) may be subject to other general exclusions and limitations of the health insurance plan, including without limitation, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of health care services including review of medical necessity, case management, and other managed care provisions.
 
Definitions:
    • Behavior Intervention Plan: A written document that describes a pattern of aberrant behavior, the environmental conditions that contribute to that pattern of behavior, the supports and interventions that will reduce the behavior and the skills that will be taught as an alternative to the behavior.
    • Core Deficits: Persistent deficits in social communication and social interaction across multiple contexts AND, restricted, repetitive patterns of behavior, interests, and activities
    • Functional Behavior Assessment: A set of descriptive assessment procedures designed to identify environmental events that occur just before and just after occurrences of potential target behaviors and that may influence those behaviors. That information may be gathered by interviewing the member’s caregivers; having caregivers complete checklists, rating scales, or questionnaires; and/or observing and recording occurrences of target behaviors and environmental events in everyday situations. (AMA CPT, 2021)
    • Generalization: The ability to complete a task, perform an activity, or display a behavior across different settings, contexts, people, and times.  
    • Mastery Criteria: An objectively and quantitatively stated standard of performance, such as a percentage, frequency or intensity, or duration, used to determine whether an individual has acquired a skill or behavior, including generalization and maintenance.  
    • Non-standardized instruments: A clinical tool that measures performance but does not provide comparison between subjects. Examples include curriculum-referenced assessment, stimulus preference-assessment procedures, and other procedures for assessing behaviors and associated environmental events that are specific to the individual patient and behaviors. (AMA CPT, 2021)
    • Standardized Assessments: A fixed set of questions that are administered and scored in a uniform way with all subjects in order to measure relative performance among a group of individuals.
 
Please refer to Guidelines for Treatment Record Documentation section of Lucet Behavioral Health Services and Solutions Provider Manual for standards on client file documentation.
 
Lucet Behavioral Health Services and Solutions will review requests for ABA treatment benefit coverage based upon clinical information submitted by the provider.
 
 
Coverage Criteria for ABA Services:
 
ABA Pre-Treatment Assessment Request
Must meet all the following criteria:
 
    1. The member has a diagnosis of Autism Spectrum Disorder (ASD) based on criteria used in the current DSM, from a clinician who is licensed and qualified to make such a diagnosis. Such clinicians are usually a neurologist, developmental pediatrician, pediatrician, psychiatrist, licensed clinical psychologist or medical doctor experienced in the diagnosis of ASD. State law may define eligible qualified clinicians.
        1. Documentation of the diagnosis must be accompanied by a clinical note of sufficient depth that allows concordance with current DSM criteria for core symptoms of ASD. Please note: Results of autism screening measures are not an autism diagnosis; a complete diagnostic evaluation must be completed, including an ASD-specific standardized assessment.
        2. The comprehensive evaluation must rule out behavior/medical diagnoses that may have similar symptom presentations. This includes neurological disorders, hearing disorders, behavior disorders and other developmental delays.
    2. Member is within the age range specified in the applicable health plan’s member service plan description or in the applicable state law for treatment.
    3. Hours requested are not more than what is required to complete the pre-treatment assessment.
 
Note: Only CPT codes identified in this document will be approved for the ABA assessment process. Standardized psychological testing services are billed with specific psychological testing AMA-CPT code by eligible providers. Typically, only a clinical psychologist is qualified to provide testing services.
 
Initial ABA Treatment Authorization Request
Must meet all the following criteria:
 
    1. Diagnostic Criteria as set forth in the previous section are met.
    2. Documentation of psychological assessment, including autism-specific testing, adaptive behavior testing and cognitive evaluation to define baseline functioning. Any assessment should be accompanied by a formal report detailing the scores achieved and the results of the assessment.
    3. The following baseline data must have been completed prior to or scheduled within 90 days of the assessment. Baseline data must have been completed no longer than 5 years prior to the pre-treatment assessment or as indicated below
        1. Developmental and cognitive evaluation
        2. Autism-specific assessment that identifies the severity of the condition
        3. Adaptive behavior assessment completed within 6 months of start date of treatment
        4. Neurological evaluation as part of a comprehensive physical examination
        5. Information required by state law
    4. Treatment goals and clinical documentation must be focused on active ASD core symptoms, deficits that inhibit daily functioning, and aberrant behaviors that require the expertise of a Behavior Analyst. The treatment goals include a plan for stimulus and response generalization in novel contexts.
    5. ABA treatment is not designed to attain academic performance.
    6. ABA treatment is not a substitute for psychotherapy, occupational therapy or other medical or behavioral health services.  
    7. Detailed, individualized coordination of care, safety planning, and discharge planning are conducted on an ongoing basis as part of treatment planning. ABA services do not duplicate services that directly support academic achievement goals that are or could be included in the member’s educational setting or the academic goals encompassed in the member’s Individualized Education Plan (IEP)/Individualized Service Plan (ISP). This includes shadow, para-professional, interpersonal or companion services in any setting that are implemented to directly support academic achievement goals.
    8. For Comprehensive treatment, the requested ABA services are designed to reduce the gap between the member’s chronological and developmental ages such that the member is able to develop or restore function to the maximum extent practical; OR  
    9. For Focused treatment, the requested ABA services are designed to reduce the burden of selected treatment targeted symptoms on the member, family and other significant people in the environment, and to target increases in appropriate alternative behaviors.
    10. Treatment is provided in the setting and intensity that is appropriate for the member’s clinical needs, determined by where target behaviors are occurring and where treatment is likely to impact those target behaviors.  
    11. Direct line therapy services are provided in a manner consistent with the Lucet Provider Manual, the Ethics Code for Behavior Analysts and applicable state laws.  In the absence of a state law, line therapy services are to be provided by a Registered Behavior Technician (RBT), Board Certified Assistant Behavior Analyst, or Master level or Doctoral level Board Certified Behavior Analyst.
    12. The treatment plan must include a plan to support the member’s ability to generalize skills across stimuli, contexts and individuals, via caregiver training or an appropriate alternative. Provider should be able to demonstrate how  instructional control will be transferred to caregivers.
        1. In the absence of successful caregiver involvement in treatment, provider should identify an appropriate alternate plan to promote the member’s ability to generalize skills outside of therapy sessions, including post-discharge.
 
Continued ABA Treatment Authorization Request
Must meet all the following criteria
 
    1. Criteria 1-14 in the Initial ABA Treatment Authorization section are met
    2. Provider demonstrates:
        1. Documentation of clinical or social benefit to the child from treatment;
        2. Identification of new or continuing treatment goals;
        3. Development of a new or continuing treatment plan based on progress evidenced by the member’s behavioral changes and increase skill acquisition.
 
HOURS TO BE AUTHORIZED:
 
Total authorized hours will be determined based on all of the following:
    1. The current medical policy and medical necessity
    2. Provider treatment plan, that identifies suitable behaviors for treatment and improves the functional ability across multiple contexts
    3. Severity of symptoms, including aberrant behaviors
    4. Continued measurable treatment gains and response to previous and current ABA treatment
    5. Hours per week requested are not more than what is required to achieve the goals listed in the treatment plan and must reflect the member’s, caregiver’s and provider’s availability to participate in treatment
 
 
Out of State claims coding:
 
ABA service providers who are in network with their local Blue Cross and Blue Shield and who are contracted to use ABA service codes different from the approved list will be eligible for reimbursement for service codes that are equivalent to covered ABA service codes listed above. Service codes that are not equivalent to the approved service codes are not eligible for reimbursement. Approval for use of alternate service codes can be requested during the provision of ABA services.
 
 
CPT Definition of Time Spent with Patient that is Eligible for Reimbursement:
 
    • Face-to-face time for outpatient visits is reimbursable and includes:
    • Time spent with patient
    • Time spent with family
    • Time spent with patient and family
 
Activities such as review of records, arranging further services, communicating with other professionals (health care, teachers, etc.) and family are considered non-face to face services provided to the member. These may occur before or after the member visit. Providing these non-face to face services are included in the work for codes 97151 to 97158 and codes 0362T and 0373T. The non-face-to-face activities are not eligible for claims submission independent of face-to-face time. (CPT 2021).
 
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Applied behavioral analysis for individuals with Autism Spectrum Disorder not meeting the criteria listed above, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For contracts without primary coverage criteria, applied behavioral analysis for individuals with Autism Spectrum Disorder not meeting the criteria listed above is considered investigational. Investigational services are specific contract exclusion in most member benefit certificates of coverage.
 
 
Due to the detail of this policy, the document containing the coverage statements for dates prior to January 2024 are not online. If you would like a hardcopy print, please email: codespecificinquiry@arkbluecross.com
Rationale:
A total of fifteen studies were included for review (3 randomized, controlled trials (RCT) and 12 non-randomized, comparative studies) that met selection criteria.  In one of the RCT’s (Sallows and Graupner, 2005), children in both the experimental and control groups improved significantly over time, but there was no statistically significant difference between groups.  Another RTC (Smith, 2000), found significantly better cognitive and communication skills in the experimental group but no difference in adaptive skills. A more comprehensive and better constructed study, the Early Start Denver Model (Dawson et al, 2009) found significant improvement in IQ, language, and adaptive behavior in toddlers (18 to 30 months) who received 20 hours per week of therapy for 2 years compared to a control group of children who received community available therapy.  Diagnostic assignment also improved significantly in the experimental group (29% improved from autistic disorder to PDD), but no significant change in ADOS severity scores.
 
The non-randomized, comparative studies include the seminal study by Lovaas et al (1987; McEachin, 1993).  While these original studies involved a clinic-based ABA therapy program, other studies have compared home-based, community-based, school-based, residential, and outpatient programs.  All of the studies were small, involved children between 15 months to 7 years of age, and utilized IBI at a high level (Lovaas, 40 hours/week of in center, therapist let treatment).  They reported significant improvement in 47% of children with subsequent follow-up (McEachin, 1993) durable improvement sustained for 5 years. This study had a number of serious flaws: small sample size (n=59), no randomization, selection bias (exclusion of low-functioning autistic children), non-standard endpoints, focus on IQ and school placement overlooked other important social and behavioral impairments, and important differences in male:female ratios.  In addition, review has suggested that a select subgroup of children were responsible for the overall changes in the intervention group: the 9 individuals described as “normal functioning” after treatment had a mean IQ gain of 37 points compared to the other 10 members of the intervention group who had a mean gain of only 3 points.  Others note that this degree of improvement has not been replicated in any other subsequent study. Overall this research has been criticized for producing unrealistic expectations about the ability of EIBI to help ASD children attain normal developmental status.
 
In 2004, Shea noted that the results of these early studies have been misstated and misinterpreted by advocates of EIBI and called upon professionals to acknowledge that while EIBI may be beneficial in some ASD individuals, there is no evidence to point to “recovery” or cure. A systematic review by Bassett et al (2000) concluded that while many forms of EIBI benefit ASD, “there is insufficient, scientifically-valid effectiveness evidence to establish a causal relationship between a particular program of intensive, behavioral treatment, and the achievement of ‘normal functioning’.”
 
Within this category, [EIBI] report greater improvements in cognitive performance, language skills, and adaptive behavior skills than broadly defined eclectic treatments available in the community. However, strength of evidence is currently low.  Further, not all children receiving intensive intervention demonstrate rapid gains, and many children continue to display substantial impairment.  Although positive results are reported for the effects of intensive interventions  that use a developmental framework, such as the Early Start Denver Model (ESDM), evidence for this type of intervention is currently insufficient because few studies have been published to date.
 
Less intensive interventions focusing on providing parent training for bolstering social communication skills and managing challenging behaviors have been associated in individual studies with short-term gains in social communication and language use.  The current evidence base for such treatment remains insufficient, with current research lacking consistency in interventions and outcomes assessed.
 
Although all of the studies of social skills interventions reported some positive results, most have not included objective observations of the extent to which improvements in social skills generalize and are maintained within everyday peer interactions.  Strength of evidence is insufficient to assess effects of social skills training on core autism outcomes for older children or play-and interaction-based approaches for younger children.
 
In summary, while there is some evidence to support the premise that EIBI promotes gains in cognitive function, language skills, and adaptive behavior in young children with autism, overall the quality and consistency of results of this research are weak. Weaknesses in research design and analysis coupled with inconsistent results lead to important questions about the benefit of an expensive and intensive intervention.  There is a need for larger, RTC studies to clarify the uncertainty about the effectiveness of EIBI for ASD.  Until better research is completed, EIBI does not meet the Primary Coverage Criteria for evidence of effectiveness.
 
2012 Update
There were no new randomized controlled trials identified in interval literature. The Agency for Healthcare Research and Quality published (AHRQ, 2011) an evaluation of therapies for children with ASD between the ages of 2-12 focusing on treatment outcomes. They noted only 2 RCT’s with only one rated as good quality.  They concluded that: “Some behavioral and educational interventions that vary widely in terms of scope, target, and intensity have demonstrated effects, but the lack of consistent data limits our understanding of whether these interventions are linked to specific clinically meaningful changes in functioning.  The needs for continuing improvements in methodologic rigor in the field and for larger multisite studies of existing interventions are substantial.  Better characterization of children in these studies to target treatment plans is imperative.”  Similarly, a recent Cochrane review (Reichow, 2012) of EIBI for ASD noted: “There is some evidence that EIBI is an effective behavioral treatment for some children with ASD.  However, the current state of the evidence is limited because of the reliance on data from non-randomized studies (CCT’s) due to the lack of RCT’s.  Additional studies using RCT research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD. The following clinical trial was identified from ClinicalTrials.gov: NCT00698997.
 
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through November 2019. The key identified literature is summarized below.
 
Reichow et al (2018) published an update of a 2012 Cochrane review of the evidence for the effectiveness of early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Effective outcomes included increased functional behaviors and skills, decreasing autism severity, and improving intelligence and communication skills for young children with ASD. Selection criteria were randomized control trials (RCTs), quasi‐RCTs, and controlled clinical trials (CCTs) in which EIBI was compared to a no‐treatment or treatment‐as‐usual control condition. The participants must have been less than six years of age at treatment onset and assigned to their study condition prior to commencing treatment.  Five studies were identified (one RCT and four CCTs) with a total of 219 children: 116 children in the EIBI groups and 103 children in the generic, special education services groups. The age of the children ranged between 30.2 months and 42.5 months. Three of the five studies were conducted in the USA and two in the UK, with a treatment duration of 24 months to 36 months. All studies used a treatment‐as‐usual comparison group. The authors concluded that there was weak evidence that EIBI may be an effective behavioral treatment for some children with ASD. The authors reported that the strength of the evidence in the review was limited because the majority of the evidence came from small studies that were not of the optimum design. Due to the inclusion of non‐randomized studies, the overall quality of evidence was rated as 'low' or 'very low' using the GRADE system. It is important that providers of EIBI are aware of the current evidence and use clinical decision‐making guidelines, such as seeking the family’s input and drawing upon prior clinical experience, when making recommendations to clients on the use EIBI. Additional studies using rigorous research designs are needed to make stronger conclusions about the effects of EIBI for children with ASD.
 
The Agency for Healthcare Research and Quality (2017) published an update of a 2011 comparative effectiveness review on the effectiveness and safety of interventions targeting sensory challenges in children with autism spectrum disorder (ASD). Studies included in the review were those comparing interventions incorporating sensory-focused modalities with alternative treatments or no treatment. Studies had to include at least 10 children with ASD ages 2–12 years. Data was summarized qualitatively because of the heterogeneity of the data. Strength of evidence was also assessed.  24 unique comparative studies (17 newly published studies and 7 studies addressed in our 2011 review of therapies for children with ASD) were identified and included 20 randomized controlled trials (RCTs), 1 nonrandomized trial, and 3 retrospective cohort studies (3 low, 10 moderate, and 11 high risk of bias [ROB]). The review concluded that some interventions targeting sensory challenges may produce modest short-term (<6 months) improvements, primarily in sensory-related outcomes and outcomes related to ASD symptom severity; however, the evidence base for any category of intervention is small, and durability of effects beyond the immediate intervention period is unclear. Sensory integration–based approaches improved outcomes related to sensory challenges (low SOE) and motor skills (low SOE), and massage improved sensory responses (low SOE) and ASD symptoms (low SOE). Environmental enrichment improved nonverbal cognitive skills (low SOE). Auditory integration–based approaches did not improve language outcomes (low SOE). Some positive effects were associated with other approaches studied (music therapy, weighted blankets), but findings in these small studies were not consistent (insufficient SOE). Data on longer term results are lacking, as are data on characteristics that modify outcomes, effectiveness of interventions across environments or contexts, and components of interventions that may drive effects. In sum, while some therapies may hold promise and warrant further study, substantial needs exist for continuing improvements in methodologic rigor in the field.
 
Touzet et al (2017) published an article describing a randomised controlled trial on the impact of the Early Start Denver Model on the cognitive level of children with autism spectrum disorder (ASD). The study was a multicenter (4 centers in France, 1 center in Switzerland and 1 center in Belgium), randomized, controlled, single blind trial using a modified Zelen design. Children aged 15-36 months, diagnosed with ASD and with a developmental quotient (DQ) of 30 or above on the Mullen Scale of Early Learning (MSEL) were included. Expected enrollment is 180 children (120 in the control and 60 in the intervention group). The experimental group will receive 12 hours per week ESDM by trained therapists 10 hours per week in the centre and 2 hours in the toddlers' natural environment (alternating between the therapist and the parent). The control group will receive care available in the community. The primary outcome will be the change in cognitive level measured with the DQ scored at 2 years. Secondary outcomes will include change in autism symptoms, behavioral adaptation, communicative and productive language level, sensory profile and parents' quality of life. The primary analysis will use the intention-to-treat principle. As of April 2019, this clinical trial (NCT02608333) was still recruiting with an estimated completion date of September 30, 2021.  
 
Mohammadzaheri et al (2015) published the results of a randomized control trial that compared two intervention conditions, a naturalistic approach, Pivotal Response Treatment (PRT) with a structured ABA approach on disruptive behavior during language intervention in the public schools. A Randomized Clinical Trial (RCT) design was used with the two groups of children that were matched according to age, sex and mean length of utterance. Thirty elementary school children (18 boys and 12 girls), ages 6 to 11 years old, participated in this study. Each child was diagnosed with autism by a child psychiatrist according to the DSM-IV-TR (American Psychiatric Association, 2000) and was referred the to the Hamaden University of Medical Sciences and Health Services in Iran for autism intervention. The data showed that the children demonstrated significantly lower levels of disruptive behavior with the PRT method of treatment.
 
Pickles et al (2016) published the results of a long-term follow-up of a randomized controlled trial on parent-mediated social communication therapy for young children with autism. This study was a follow-up of the Preschool Autism Communication Trial (PACT) to investigate whether the PACT intervention had a long-term effect on autism symptoms and continued effects on parent and child social interaction. PACT was a randomized controlled trial of a parent-mediated social communication intervention for children aged 2-4 years with core autism. Follow-up ascertainment was done at three specialized clinical centers in the UK (London, Manchester, and Newcastle) at a median of 5.75 years from the original trial endpoint. The main blinded outcomes were the comparative severity score (CSS) from the Autism Diagnostic Observation Schedule (ADOS), the Dyadic Communication Assessment Measure (DCMA) of the proportion of child initiations when interacting with the parent, and an expressive-receptive language composite. All analyses followed the intention-to-treat principle. PACT is registered with the ISRCTN registry, number ISRCTN58133827. 121 (80%) of the 152 trial participants were traced and consented to be assessed between July 2013, and September 2014. Mean age at follow-up was 10.5 years. The authors purported that the results were the first evidence to show long-term symptom reduction after a randomized controlled trial of early intervention in autism spectrum disorder. They support the clinical value of the PACT intervention and its implications on developmental theory.
 
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through October 2020. No new literature was identified that would prompt a change in the coverage statement.
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through October 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through October 2022. No new literature was identified that would prompt a change in the coverage statement.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through October 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2023 Update
Annual policy review completed with no change.
CPT/HCPCS:
0362TBehavior 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.
0373TAdaptive 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.
97151Behavior 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
97152Behavior 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
97153Adaptive 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
97154Group 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
97155Adaptive 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
97156Family 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
97157Multiple 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
97158Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face to face with multiple patients, each 15 minutes
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