Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

Autism Spectrum Disorder in Adults, Applied Behavioral Analysis

Description:

Autism spectrum disorder (ASD) is a lifelong biologically based neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction and restricted, repetitive patterns of behavior, interests, and activities. ASD can range from mild social impairment to severely impaired functioning; as many as half of individuals with autism are non-verbal and have symptoms that may include debilitating intellectual disabilities, inability to change routines, and severe sensory reactions. The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5) provides standardized criteria to help diagnose ASD (APA, 2013). Autism can co-occur with other mental health diagnoses, including, but not limited to, depression, anxiety disorders (eg, social anxiety, obsessive-compulsive disorder), attention deficit hyperactivity disorder, Tourette syndrome/tic disorder, personality disorder, and/or psychosis (NICE, 2022).

Diagnosis of ASD in the United States (U.S.) generally occurs in 2 steps: developmental screening followed by comprehensive diagnostic evaluation if screened positive. The American Academy of Pediatrics (AAP) recommends general developmental screening at 9, 18, and 30 months of age and ASD-specific screening at 18 and 24 months of age (Lipkin, 2020; Hyman, 2020). Diagnosis and treatment in the first few years of life can have a strong impact on functioning since it allows for treatment during a key window of developmental plasticity (Dawson, 2013; Dawson, 2010). However, early diagnosis in the US remains an unmet need even though studies have demonstrated a temporal trend of decreasing mean age at diagnosis over time (Hertz-Picciotto, 2009; Leigh, 2016).

ASD is a lifelong condition; however, relatively little work has investigated the most effective treatments in adults. Per a study from the Centers for Disease Control and Prevention (CDC), an estimated 5,437,988 adults (2.21%) in the U.S. have ASD, with many requiring ongoing services and support (Dietz, 2020). Treatments for ASD can be generally broken down into the following categories, although some treatments involve more than one approach: behavioral, developmental, educational, social-relational, pharmacological, psychological, and complementary/alternative (CDC, 2022), The gold standard therapy for the core symptoms of ASD is behavioral therapy (Frye, 2022). Additionally, many individuals with ASD have abnormalities in multiple organs (eg, brain, immune system, gastrointestinal system) and may be adversely impacted by environmental factors including psychosocial stress, dietary limitations, and allergen exposure. Although it is unclear whether these issues are related to the etiology of ASD, there is evidence that these factors can alter ASD symptoms, which makes them potential therapeutic targets.

Applied Behavior Analysis

Applied behavior analysis (ABA) is therapeutic approach comprised of multiple techniques in which environmental variables are identified that influence socially significant behavior and are used to develop individualized and practical strategies to teach basic skills such as communication, adaptive skills, or social interactions. These relevant environmental events are usually identified through a variety of specialized assessment methods. ABA is based on the fact that an individual's behavior is determined by past and current environmental events in conjunction with organic variables such as genetic endowment and physiological variables. When applied to ASD, ABA focuses on treating the problems of the disorder by altering the individual's social and learning environments.

ABA treatment models can generally be classified as focused or comprehensive (CAS Providers, 2022). Focused ABA refers to treatment provided directly to the individual for a limited number of behavioral targets and may involve increasing socially appropriate behavior or reducing problem behavior as the primary target. Focused ABA is appropriate for individuals who need treatment only for a limited number of key functional skills or have such acute problem behavior that its treatment should be the priority. Comprehensive ABA refers to treatment of the multiple affected developmental domains (eg, cognitive, communicative, social, emotional, and adaptive functioning) and maladaptive behaviors. Initially, treatment is typically provided in structured therapy sessions, which are integrated with more naturalistic methods as appropriate. As the individual progresses and meets established criteria for participation in different settings, treatment in those settings and in the larger community should be provided. ABA therapy may be performed by, or supervised by, a certified ABA provider, such as a licensed applied behavior analyst (LABA) or a trained, licensed psychologist. Clinical guidance has identified ABA and/or other developmental and naturalistic approaches as examples of potential components to include in a Comprehensive Treatment Model in children with ASD. ABA is also being evaluated to aid in the treatment of ASD into adulthood.

Regulatory Status

ABA is not subject to regulation by the U.S. Food and Drug Administration.

Policy/
Coverage:

Effective April 15, 2023

Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria

Applied behavioral analysis for individuals who are 18 years of age or older with autism spectrum disorder does not meet member benefit certificate primary coverage criteria.

For members with contracts without primary coverage criteria applied behavioral analysis for individuals who are 18 years of age or older with autism spectrum disorder is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.

Rationale:

New policy created with literature review through August 31, 2022.

Autism Spectrum Disorder in Adults

Systematic Reviews

Bishop-Fitzpatrick et al conducted a systematic review that evaluated the evidence base regarding psychosocial interventions for adults with ASD (Bishop-Fitzpatrick, 2013). A total of 13 studies were included. These studies had diverse methodologies and represented various interventional categories. Of the 13 trials, 5 were single case studies, 4 were RCTs, 3 were non-randomized controlled trials, and 1 was an uncontrolled pre-post trial. The efficacy of ABA techniques was evaluated in the 5 single case studies of 5 individuals, the majority of whom had coexisting developmental disorders. The remaining trials evaluated the efficacy of social cognition training (6 studies) and other types of community-based interventions (2 studies).

With regard to ABA, all single case studies sought to reduce instances of an undesirable behavior (eg, coprophagia, repeated inappropriate gestures, or verbal perseverations) or increase instances of a desirable behavior (eg, social interaction or compliance with a medical procedure) (Bishop-Fitzpatrick, 2013). The results from all case studies reported positive benefits of ABA interventions; however, the maintenance of the benefit varied among the studies. ABA interventions included positive reinforcement, mild reprimands, reciprocal statements, and stimulus fading depending on the change in behavior sought. Despite the potential benefits of ABA described in the systematic review, the results are significantly limited by the small number of single case studies (n=5) included, heterogeneity in the ABA approaches and potential concomitant therapy, unclearly defined treatment histories, unclearly defined qualifications of staff and therapists, and lack of utilization of outcome assessment instruments with prespecified clinically meaningful improvement thresholds. There is a substantial need for continued development and evaluation of psychosocial treatments, including ABA, for adults with ASD.

The National Institute for Health and Clinical Excellence (NICE) also conducted an evidence review in 2012 on the diagnosis and management of ASD, which was last updated in June 2021 (NICE, 2022). However, ABA is not specifically mentioned. Various psychosocial interventions are recommended for the core features of autism, to improve life skills, for challenging behaviors, and for those with concurrent mental disorders.

Practice Guidelines and Position Statements

National Institute for Health and Care Excellence

NICE issued a clinical guideline on the diagnosis and management of autism spectrum disorder (ASD) in adults in 2012, which was last updated in June 2021 (NICE, 2022). The NICE guidance provides recommendations for general principles of care; identification and assessment; identifying the correct interventions and monitoring their use; interventions for autism, behavior that challenges, and coexisting mental disorders; assessment and interventions for families, partners, and carers; and organization and delivery of care (NICE, 2022). Applied behavior analysis is not specifically mentioned but rather various psychosocial interventions are recommended for the core features of autism, to improve life skills, for challenging behaviors, and for those with concurrent mental disorders.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in August 2022 did not identify any ongoing or unpublished trials that would likely influence this review.

2024 Update

Annual policy review completed with a literature search using the MEDLINE database through December 2023. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:

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.
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.
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

References:

American Psychiatric Association.(2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Washington, DC: American Psychiatric Association; 2013.

Baker D, Valenzuela S, Wieseler N.(2005) Naturalistic inquiry and treatment of coprophagia in one individual. J Developmental Phys Disabilities. 2005;17(4):361-367.

Bishop-Fitzpatrick L, Minshew NJ, Eack SM.(2013) . A systematic review of psychosocial interventions for adults with autism spectrum disorders. J Autism Dev Disord. Mar 2013; 43(3): 687-94. PMID 22825929

Bolte S, Feineis-Matthews S, Leber S, et al.(2002) The development and evaluation of a computer-based program to test and to teach the recognition of facial affect. Int J Circumpolar Health. 2002; 61 Suppl 2: 61-8. PMID 12585821

Centers for Disease Control and Prevention.(2022) Treatment and intervention services for autism spectrum disorder. March 2022. https://www.cdc.gov/ncbddd/autism/treatment.html. Accessed August 31, 2022.

Dawson G, Bernier R.(2013) A quarter century of progress on the early detection and treatment of autism spectrum disorder. Dev Psychopathol. Nov 2013; 25(4 Pt 2): 1455-72. PMID 24342850

Dawson G, Rogers S, Munson J, et al.(2010) Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics. Jan 2010; 125(1): e17-23. PMID 19948568

Dietz PM, Rose CE, McArthur D, et al.(2020) National and State Estimates of Adults with Autism Spectrum Disorder. J Autism Dev Disord. Dec 2020; 50(12): 4258-4266. PMID 32390121

Faja S, Webb SJ, Jones E, et al.(2012) The effects of face expertise training on the behavioral performance and brain activity of adults with high functioning autism spectrum disorders. J Autism Dev Disord. Feb 2012; 42(2): 278-93. PMID 21484517

Frye RE.(2022) A Personalized Multidisciplinary Approach to Evaluating and Treating Autism Spectrum Disorder. J Pers Med. Mar 14 2022; 12(3). PMID 35330464

Gantman A, Kapp SK, Orenski K, et al.(2012) Social skills training for young adults with high-functioning autism spectrum disorders: a randomized controlled pilot study. J Autism Dev Disord. Jun 2012; 42(6): 1094-103. PMID 21915740

Garcia-Villamisar D, Hughes C.(2007) Supported employment improves cognitive performance in adults with Autism. J Intellect Disabil Res. Feb 2007; 51(Pt 2): 142-50. PMID 17217478

Garcia-Villamisar DA, Dattilo J.(2010) Effects of a leisure programme on quality of life and stress of individuals with ASD. J Intellect Disabil Res. Jul 2010; 54(7): 611-9. PMID 20500784

Golan O, Baron-Cohen S.(2006) Systemizing empathy: teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia. Dev Psychopathol. 2006; 18(2): 591-617. PMID 16600069

Hyman SL, Levy SE, Myers SM, et al.(2020) Identification, Evaluation, and Management of Children With Autism Spectrum Disorder. Pediatrics. Jan 2020; 145(1). PMID 31843864

Leigh JP, Grosse SD, Cassady D, et al.(2016) Spending by California's Department of Developmental Services for Persons with Autism across Demographic and Expenditure Categories. PLoS One. 2016; 11(3): e0151970. PMID 27015098

Lipkin PH, Macias MM, Norwood KW, et al.(2020) Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics. Jan 2020; 145(1). PMID 31843861

McDonald ME, Hemmes NS.(2003) Increases in social initiation toward an adolescent with autism: reciprocity effects. Res Dev Disabil. Nov-Dec 2003; 24(6): 453-65. PMID 14622895

Moore TR.(2009) A brief report on the effects of a self-management treatment package on stereotypic behavior. Research in Autism Spectrum Disorders. 2009;3:695-701.

National Institute for Health and Care Excellence.(2022) National Institute for Health and Care Excellence: Autism spectrum disorder in adults: diagnosis and management. Last updated June 14, 2021. https://www.nice.org.uk/guidance/cg142. Accessed September 8, 2022.

National Institute for Health and Clinical Excellence.(2022) Autism. Recognition, referral diagnosis and management of adults on the autism spectrum. National clinical guideline number 142. 2012. https://www.nice.org.uk/guidance/cg142/evidence/full-guideline-pdf-186587677. Accessed September 20, 2022.

Rehfeldt RA, Chambers MR.(2003) Functional analysis and treatment of verbal perseverations displayed by an adult with autism. J Appl Behav Anal. 2003; 36(2): 259-61. PMID 12858991

Shabani DB, Fisher WW.(2006) Stimulus fading and differential reinforcement for the treatment of needle phobia in a youth with autism. J Appl Behav Anal. 2006; 39(4): 449-52. PMID 17236343

The Council of Autism Service Providers.(2022) . Applied behavioral analysis treatment of autism spectrum disorder: practice guidelines for healthcare funders and managers. 2nd ed. 2014. https://casproviders.org/wp-content/uploads/2020/03/ABA-ASD-Practice-Guidelines.pdf. Accessed August 31, 2022.

Trepagnier CY, Olsen DE, Boteler L, et al.(2011) Virtual conversation partner for adults with autism. Cyberpsychol Behav Soc Netw. Jan-Feb 2011; 14(1-2): 21-7. PMID 21329439

Turner-Brown LM, Perry TD, Dichter GS, et al.(2008) Brief report: feasibility of social cognition and interaction training for adults with high functioning autism. J Autism Dev Disord. Oct 2008; 38(9): 1777-84. PMID 18246419

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.