Applied Behavior Analysis for Autism Spectrum Disorder

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 07/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standar ds, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………. 2 B. Background ………………………….. ………………………….. ………………………….. ……………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………… 4 D. Policy ………………………….. ………………………….. ………………………….. ………………………. 5 E. Conditions Of Coverage ………………………….. ………………………….. ………………………… 13 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. 14 G. Review/Revision History ………………………….. ………………………….. ……………………….. 15 H. References ………………………….. ………………………….. ………………………….. …………….. 15 Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectApplied Behavior Analysis Therapy for Autism Spectrum Disorder B. BackgroundThe Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, Text Revised (DSM-5-TR) classifies Autism Spectrum Disorder (ASD) as a neurodevelopmental disorder var ies widely in severity and symptoms, depending on the developmental level and chronological age of the individual . ASD is characterized by specific developmental deficits that affect socialization, communication, academic and personal functioning . Individuals are typically diagnosed before entering grade school, and symptoms are noticed acr oss multiple contexts, including social reciprocity, nonverbal communicative behaviors, and skills in developing, maintaining and understanding relationships. Restricted, repetitive patterns of behavior, interests or activities are also often present. Currently, th ere is no cure for ASD, nor is there any single treatment for the disorder.The diagnosis may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions with a goal of minimiz ing the severity of ASD symptoms, maximiz ing learning, facilitat ing social integration, and improv ing quality of life for the member and fami ly/caregiver (s). Applied behavior analysis (ABA), one such therapy, may be provided in centers or at home and provi des an evidence-ba se d practice for the treatment of ASD. ABA is based on the science of behavior, which was founded on the premise that understanding behavior functioning, how it is affected by the environment, and how learning to change behavior can improve the human condition. It is a flexible treatment in tha t it should always be adapted to the needs of each individual, teaches skills that areuseful and generalizable, and involves individual, group and family training. Qualified and trained practitioners provide and/or oversee ABA programs and are accountable to state boards for registration, certification, or licensure requirements. Clinical decisions on telehealth service delivery models should be selected based on the individual needs, strengths, preference of service modality, caregiver availability , and environmental support available. CareSource follows the Ohio Administrative Code (OAC) and Ohio Department of Medicaid (ODM) guidelines in the provision of ABA services, based on a diagnosis from the DSM-5-TR . Severity levels are divided into 2 domains, social communication and restricted, repetitive behaviors: Severity Levels for Autism Spectrum DisorderSeverity Level Social Communication Restricted, repetitive behaviors Level 3 Requiring very substantial support Severe deficits in verbal & nonverbal social communication skills cause severe impa irments in functioning, very limited initiation of social interactions, Inflexibility of behavior, extreme difficulty coping with change, or other restricted/ repetitive behaviors markedly interfere with functioning in all spheres. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 and minimal response to social overtures from others. Great distress/difficulty changing focus or action. Level 2 Requiring substantial support Marked deficits in verbal and nonverbal social communication skills, social impairments apparent even with supports in place, limited initiation of social interactions, and reduced or abnormal responses to social overtures from others. Inflexibility of behavior, difficulty coping with change, or other restricted/ repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing f ocus or action. Level 1 Requiring support Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions and clear examples of atypical or unsuccessful responses to social overtur es of others. May appear to have decreased interest in social interactions. Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. Social skills instruction is an important component of management of the diagnosis.Although additional studies are necessary, a 2012 meta-analysis of five randomized trials (196 participants) found evidence that participation in social skills groups improved overall social competence and friendship quality in the short term. A 2020 study demonstrated efficacy of a modified group cognitive behavioral therapy program in children delivered in a community context. A 2021 study demonstrated benefits of group cognitive behavioral treatment in adolescents diagnosed with autism and intellectual disabilities. As children near entry in a public or private school system, research supports the use of group therapy for school readiness and improved social skills. Training must be an integral component of the management of the underlying disorder and in clude clearly defined goals, teach desired behaviors, provide prompting for natural display of desired behaviors, provide reinforcement of demonstrated behaviors, and include practice of desired behaviors with goals of generalizability outside the therapeu tic setting (eg, impairments in social-emotional reciprocity, restrictive or obsessional interests, aggressive behaviors). As the child becomes eligible for school-based services (the age varies depending uponthe state), the public school system becomes responsible for the provision of services and education. The services provided are outlined in an individualized education program (IEP), which is reviewed at a minimum of once a year, for children eligible. ASD services do not include education services otherwise available through a program funded under 20 US Code Chapter 3, section 1400 of the Individuals with Disabilities Ed ucation Act (IDEA). Congress reauthorized the IDEA in 2004 and most recently amended the IDEA through Public Law 114-95, Every Student Succeeds Act, in December 2015 Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 C. Definitions Applied Behavior Analysis (ABA ) 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. Caregiver/Family Trainin g Therapist teaches parents/caregivers to implement methods utilized in a clinical setting i nto other environments, such as the home or community, to maximize member outcomes by furthering the generalization of skills and reinforcing methods being taught to the member in other sessions. Functional Assessment The determination of underlying function or purpose of behavior to develop an effective treatment plan, including a variety of systematic, information gathering techniques regarding factors influencing behavior occurrence (eg, antecedents, consequences, s etting events and motivating operations), such as interview, indirect assessment, direct observation, descriptive assessment, experimental analysis, and systematic manipulation of environmental variables to demonstrate a relationship between an event and t argeted behavior. Independent Practitioner All ABA services must be provided by a provider/practitioner compliant with Ohio Revised Code 4783.02 with approved supervision, as applicable , including the following (not an all-inclusive list): o Board Certified Assistant Behavior Analyst (BCaBA) o Certified Ohio Behavioral Analyst (COBA) or Board-Certified Behavior Analyst (BCBA) o Board Certified Behavior Analyst – Doctoral (BCBA-D) o Registered Behavior Technician (RBT) Medically Unlikely Edit (MUE) Maximum units of service for 1 Current Procedural Terminology (CPT) code a provider can report for 1 member on 1 date of service. Standardized Diagnostic Assessment Tool s Direct assessment, e vidence – based tools designed to assist with identification of symptoms and criteria for a diagnosis or disorder. SMART Goal s Goals that are specific (S) , measurable (M) , attainable (A) , relevant (R) , and time-bound (T) . Supervisio n Directing, guiding, training , and assessing individuals who provide behavior-analytic services with responsibilities in accordance with the board from which the practitioner received a license. o BCaBAs ervices must be supervised by a COBA/ BCBA, BCBA-D, or a licensed psychologist who has tested in ABA and is certified by the American Board of Professional Psychology in Behavioral and Cognitive Psychology . Treatment Plan A written document describing presenting behavior problem(s) and behavioral goals and interventions selected to alter behavior based on information gathered from in-person assessments, review of records from other professionals, direct observation, and clinical interview data, including an estimate of the length of time and/or number of sessions anticipated to achieve goals and specific statements about the measurement of progress toward achieving goals. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 D. PolicyI. General Guidelines A. Medical necessity review is required for all ABA services initially with a baseline and then, again, every 6 months. Medical review must be submitted with appropriate documentation as indicated in this policy and align with the States definition of medical necessity that includes that treatment is not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results. B. ABA therapy should begin early in life, ideally by the age of 2, typically lasting up to 3 to 4 years and is subject to the members response to treatment. C. Members under the age of 21 will be assessed. Treatment goals and intensity will be based on individual needs and progress in treatment with a focus on remediation of symptoms. D. The members treatment record (eg, plans of care, treatment plans, behavior support plans, functional assessments ) must be completed by the provider or practitioner and submitted to CareSource prior to claim submission. Claims will not be accepted without accompanying treatment documentation. II. Initia tion of ABA ServicesA. Documentation: CareSource must receive documentation that confirms the following medical criteria: 1. definitive, primary diagnosis of ASD made by one of the following practitioner s upon evaluation : a. child and adolescent psychiatrist b. psychologist c. child neurologist d. developmental pediatrician 2. standardized diagnostic assessment tools that are considered multidisciplinary evaluations, including a. Autism Diagnostic Observation Schedule (ADOS) b. Autism Diagnostic Interview Revised (ADI-R) c. Childhood Autism Rating Scale, 2 nd edit. (CARS-2) 3. written documentation ( eg, provider letter ) that d escri bes DSM clinical symptoms present within the past year requir ing treatment if the submitted diagnostic evaluation was completed more than 24 months from date of request B. Initial Behavior Assessment: Before services are provided, an initial behavior identification assessment will be performed by a fully credentialed BCBA with state licensure, if available, and devel op a treatment plan. Generally, b ehavioral assessments are not to exceed 6-10 hours every 6 months , unless additional justification is provided. C. Initial Treatment Plan: An initial ABA treatment plan individualized to the caregiver/family needs, values, priorities and circumstances for member goals and parent/caregiver training will be developed by the member, family/caregiver, and provide r and m ust include the following: Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6 1. biopsychosocial information, including, but not limited to:a. current family structure b. medication history, including dosage and prescribing physician c. medical history d. school placement and hours in school per week, including homeschool instruction and any individualized education plans (IEP) e. history of ABA services, including service dates and progress notes f. all behavioral health diagn oses and services, including any hospitalizations g. other services member is receiving (eg, speech therapy [ST] , occupational therapy [OT], physical therapy [PT]) , including evidence of coordination with other disciplines involved in the assessment h. caregiver proficiency and involvement in treatment i. any major life changes 2. rationale for ABA services (eg, how ABA addresses current areas of need ), including the following : a. history with symptom intensity and symptom duration, including how symptoms affect the members ability to function in various settings b. evidence of previous therapy ( eg, outcomes from previous ABA treatment, ST, OT, PT) and how result s influence proposed treatment c. type, duration, frequency for services 3. goals related to core deficits ( eg, communication problems, relationship development, social and problem behaviors) must includ e the following: a. outcome driven , performance-based, and individualized measures focused on targeted symptoms, behaviors, and functional impairments b. based on the direct behavioral assessment and a standardized developmental and functional skills assessment/curriculum ( eg, Verbal Behavior Milestones Assessment and Placement Program [VB-MAPP ], Assessment of Basic Language and Learning Skills [ABLLS-R]). c. a description of treatment activities and documentation of active participation by member and caregiver/family in the implementation of treatment OR documentation detailing barriers to family/ caregiver participation and how those barriers are being actively addressed d. SMART goals that define how improvement will be noted, frequency of treatment (number of hours per week), and duration of treatment 4. Behavioral Intervention Plan and/or a Plan of Care (POC) 5. requested number of ABA hours per week based on the members specific needs , not on a general program structure , as evidenced by all of the following: a. Treatment is provided at the lowest level of intensity appropriate to the members clinical needs and goals with the number of hours requested reflecting the actual number of hours intended to be provided . b. A d etailed description of problems, goals and interventions support the requested intensity of treatment . Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.7 6. a plan to modify the intensity and duration of treatment over time based on the members progress, including an individualized discharge plan specific to treatment needs7. coordination with other behavioral health and medical providers III. Continuation of ABARequests for continuation of ABA services are to be submitted every 6 months, and documentation must meet EITHER of the following criteria: A. A d efinitive diagnosis of ASD persists , and m ember continues to demonstrate ASD symptoms that will benefit from treatment in at least 2 set tings . B. A t reatment plan as noted in D. II. C., including the following: 1. an updated progress report with assessment scores that note improvement and member response to treatment from baseline targeted symptoms, behaviors, and functional impairments using the same modes of measurement utilized for baseline measurements 2. a plan to transition services in intensity over time C. Parent/caregiver(s) are involved and making progress in development of behavioral interventions. OR D. When requesting continuation with inadequate progress on targeted symptoms or behaviors or no demonstrable progress within a 6-month period, an assessment of the reasons for lack of progress should be documented and provided. Treatment interventions should be modified to achieve adequate progress. Documentation should include 1. change in possible treatment techniques 2. increased parent/caregiver training 3. increased time and/or frequency working on specific targets 4. identification and resolution of barriers to treatment efficacy 5. any newly identified co-existing disorders and possible treatment 6. modified or removed goals and interventions IV. Discontinuation of ABA TherapyTitration or discontinuation of ABA therapy should occur when any of the following conditions are met (not an all-inclusive list): A. Treatment ceases to produce significant meaningful progress or maximum benefit has been reached . B. Member behavior does not demonstrate meaningful progress for two successive 6-month authorization periods as demonstrated via standardized assessments. C. ABA therapy worsens symptoms, behaviors or impairments. D. Symptoms stabilize allowing member to transition to less intensive treatment or level of care. E. Parents/caregivers have refused treatment recommendations, are unable to participate in the treatment program, and/or do not follow through on treatment recommendations to an extent that compromises the effectiveness of the services for member progress. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8 V. Parent/ Caregiver TrainingTraining will evolve as goals are met . Parent/caregiver should be actively working on at least 1 unmet goal . ABA services must include documentation of the following: A. understand ing and agree ment to comply with the requirements of treatment B. how the parents/caregivers will be trained in skills that can be generalized to the home and other environments C. methods by which the parents/caregivers will demonstrate trained skills D. barriers to parent involvement and plans to address (eg, are treatment goals addressed when treatment professionals are not present , overall skill abilities ) E. time involvement, including materials or meetings occurring on a routine basis VI. TelehealthParent/caregiver training and supervision may be provided by telehealth . 1:1 ABA services may be provided via telehealth in instances deemed medically necessary with supporting documentation that provides a plan for the provision of service delivery. Providers utilizing telehealth for the delivery of services must make decisions that are consistent with best, currently available evidence and clinical consensus. Clinical rationale must consider assessed needs, strengths, preferences, and available resou rces of members and caregivers. The same professional ethics governing in-person care must be followed and limitations considered, including interstate licensure challenges, state regulatory issues, member or caregiver discomfort with technology, technolog y limitations, and cultural acceptance of virtual visits. Providers must identify protocols for clinical appropriateness (eg, risk assessment, safety planning, patient/caregiver characteristics), ensure therapeutic benefit for recipients, and ensure provid er competence of delivering care via telehealth modalities. Peer reviewed studies and other best evidence literature provides guidance on appropriate screeners and questionnaires for use in the determination of appropriateness of telehealth services for pa rticular clients. VII. Documentation RequirementsThe State of Ohio enacts code related to requirements for documentation expectations for client records maintained for third party billing. Each dated entry in the professional record is maintained for a period of not less than 7 years after the last date of service or not less than the length of time required by other regulations if longer. Records documenting services rendered to minors must be retained for not less than 2 years after the minor reaches the age of majority or for 7 years after the last da te of service, whichever is longer. All written, electronic and other records will be stored and disposed of in such a manner as to ensure confidentiality . All must be legible . A. Minimum documentation requirements for ABA client records include the following: 1. presenting problem, including any relevant diagnosis and any recommendation for ABA services rendered by a licensed professional Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.9 2. date(s) and purpose of each service contact (eg, service note)3. treatment plan and functional assessment on which behavior plan is based 4. data collected to ascertain efficacy of ABA and any subsequent modifications of the plan 5. notation and results of formal contacts with other providers 6. authorizations, if any, by the client for release of records or information B. Minimum documentation requirements for all service s rendered include 1. name of provider organization clearly visible on the record 2. members name on each page (ie, legal name) with date of birth or unique identifier 3. start and stop times of the session , including any pauses in services (must indicate time paused and time resumed) 4. date and location of rendered service and date of note creation if different from date of rendered service 5. type/ code of service provided 6. provider rendering the service with appropriate credentials and dated signature 7. identification of others present, including the relationship to the member and number of individuals participating in group sessions 8. interventions occurring during the session that directly relate to the POC and client response to interventions 9. any needed modifications to treatment or items requiring follow up from previous sessions , including any addendums to the record VIII. Codes of ConductCodes of conduct exist to meet credentialing needs of professionals but also function to protect members by establishing, disseminating, and managing professional standards. Ohio mandates that providers of ABA services understand and follow codes of conduct supporting the profession. CareSource supports professional standards established by licensing and credentialing bodies, and therefore, encourages professional compliance to any and all standards across disciplines for the protection of members and famil ies. The ethics code written by the Behavior Analyst Certificat ion Board includes the following standards (not all-inclusive): A. Family oversight must occur by/with the BCBA or BCaBA. An RBT may be present during a family training session to provide assistance with interventions, but the training or supervision of interventions cannot be completed by the RBT. B. Providers will create a contract for consent to services ( eg, Declaration of Professional Practices and Procedures) at the onset of services that defines and documents, in writing, the professional role with relevant parties. C. Appropriate effort will be made to involve members and stakeholders in treatment, including selecting goals, designing assessments and interventions, and conducting continual progress monitoring. D. Providers will identify and address environmental conditions ( eg, behavior of others, hazards to client or staff) that may interfere with service delivery, Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.10 including the identification of effective modifications to interventions and appropriate documentation of conditions, actions taken, and eventual outcomes.E. Continuity of services will be facilitated to avoid interruption or disruption of services for members, including documentation of actions taken and eventual outcomes. F. Providers will address any possible circumstances when relevant stakeholders are not complying with the behavior-change intervention(s) despite documented and appropriate efforts to address barriers to treatment. IX. Supervision ExpectationsThe State of Ohio enacts code for supervision requirements and documentation expectations for providers within the profession . The BACB provides guidelines for supervision requirements and documentation expectations for providers within the profession. If there are discrepancies with supervision documentation, the associated claims are subject to recoupment. A. At a minimum, supervision must include the following activities : 1. consultation with the supervisee(s) prior to initiation of the treatment plan 2. training regarding implementation of the treatment plan, data collection regarding effectiveness, and measurement of client progress 3. consultation with the supervisee(s) prior to modification of the treatment plan 4. periodic direct observation of each supervisee implementing assessment and treatment procedures with clients, including performance evaluation and additional instruction as necessary B. Record Maintenance Supervision records will be maintained by certified Ohio behavior analysts for a period of 5 years , BCBAs /RBTs for 7 years , following the termination of supervision, which include the following documents , at a minimum: 1. supervision plans for each client treatment plan 2. dates of training on treatment plans, procedures, and interventions 3. supervision provided when treatment plans are reviewed or modified C. General supervision documentation records must include the following information (not an all-inclusive list) : 1. date and start/stop time s of supervision session 2. names, credentials and/or relationship of individuals present at each session 3. type of supervision (general or direct) 4. purpose of supervision, including any collaborati on of care among providers 5. outcome of supervision, including any modification to treatment inventions or plans of care, including the following information: a. review of services provided b. review of data forming basis of a continued treatment plan c. review of client progress, including results of tools noting progress 6. name and credentials of the supervisor (if documenting for billing purposes, the supervisors National Provider Identifier), included dated signature 7. dated signature of supervisee, including credentials Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.11 D. The BACB outlines the following minimum provisions for supervision documentation:1. RBTs must document the following during supervision (not all-inclusive): a. days and times behavior-analytic services were provided b. dates and duration of supervision c. supervision format (individual, group) d. dates of direct observation e. names of supervisors providing supervision f. noncertified RBT supervisor form, if applicable g. proof of supervisors relationship to the client h. additional documentation in the event of discrepant records (session notes) 2. Supervisors must document the following for any supervision hours conducted (not an all-inclusive list): a. date with start and stop times b. fie ldwork type c. supervision type (group, individual) d. activity category (restricted or unrestricted) e. summary of supervision activity, including 01. discussion of activities completed during independent hours and any feedback provided 02. progress toward individual member goals 03. outcome of supervision, including any modification to treatment interventions or plans of care 04. collaboration of care among providers f. dated signatures of supervisor and supervisee, including credentials 3. Observations must include the following (at a minimum): a. date with start and stop times b. fieldwork type c. setting name d. supervisor name e. activity category (restricted or unrestricted) E. CareSource supports BACB published ethical codes related to supervision for the provision of services to clients, including, but not limited to 1. Behavior analysts (BA) are knowledgeable about and comply with all applicable supervisory requirements, funder and organization policies), including those related to supervision modalities and structure. 2. BAs supervise and train others only within an individual identified scope of competence. 3. BAs take on only the number of supervisees allowing effective supervision and training. When a threshold volume for providing effective supervision has been met, documentation of this self-assessment and communication of results to employer(s) and rel evant parties must occur. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12 4. BAs are accountable for supervisory practices and professional activities(eg, client services, supervision, training, research activity, public statements) of supervisees occurring as part of that relationship. 5. BAs ensure that documentation, and the documentation of supervisees or trainees, is accurate and complete. 6. BAs deliver supervision and training in compliance with applicable requirements (eg, BACB rules, licensure requirements, funder and organization policies) and design and implement supervision and training procedures that are evidence based, focus on p ositive reinforcement, and are individualized for each supervisee and circumstances. 7. BAs actively engage in continual evaluation of supervisory practices using feedback from others and client and supervisee outcomes. Self – evaluations are documented and timely adjustments made to supervisory and training practices as indicated. X. Special Provisions Related to RBTsA. Current Standards for RBTs 1. RBT services must be supervised by a qualified RBT supervisor. RBTs must obtain ongoing supervision for a minimum of 5% of the hours spent providing ABA services per month. Additionally, the BACB publishes information regarding the structure of supervision and parameters for group and individual supervision in the RBT Handbook. 2. An RBT who is certified by the BACB may provide ABA under the supervision of an independent practitioner if enrolled in the Medicaid program and affiliated with the organization under which the provider is employed or contracted. If the independent practitioner leaves the affiliated organization and no longer provides supervision, the RBT may not continue to provide services under that independent practitioner . Additionally, if the RBT leaves the affiliated organization and no longer receives mandated supervision, the RBT may not continue to provide services to the member. 3. RBTs must use appropriate modifiers that indicate qualifications of staff delivering services , if appropriate. B. Upcoming RBT Changes from the Behavior Analyst Certification Board 1. Effective January 1, 2026: In the interest of consumer protection, the BACB Board of Directors approved a recommendation that RBT supervisors must hold BCBA or BCaBA certification. Noncertified supervisors will not be allowed to provide BACB-required supervision to RBTs. During this transition, RBT Requirements Coordinators who currently attest to the qualifications of noncertified supervisors should make preparations to ensure continuity of care for clients. 2. Effective January 1, 2026: New rules regarding e ligibility for and maintenance of certification for RBTs were adopted by the BACB Board of Directors and can be located in the BACB Newsletter: December 2023 at www.bacb.com. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.13 XI. ExclusionsA. reimbursement for the following services or activities is not permitted: 1. any services not documented in the treatment pla n 2. behavioral methods or modes considered experimental 3. education-related services or activities described under Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. 1400 (IDEA) , amended through Public Law 114-95, the Every Student Succeeds Act 4. vocational services in nature or those available through program s funded under Section 110 of the Rehabilitation Act of 1973 5. components of adult day care programs B. treatment solely for the benefit of the family, caregiver , or therapist C. treatment focused on recreational or educational outcomes D. treatment worsening symptoms or prompting member regression E. treatment for sy mptoms and behaviors not part of core symptoms of ASD ( eg, impulsivity due to ADHD, reading difficulties due to learning disabilities, excessive worry due to an anxiety disorder) F. goals focused on academic targets ( eg, treatment should address autistic symptoms impeding deficits in the home environment , such as reduc tion of frequency of self-stimulatory behavior to follow through with toilet training or complet ing a mathematic sorting task) G. treatment unexpected to cause measurable , functional improvement or improvement is not documented H. duplicative t herapy services addressing the same behavioral goals using the same techniques as the treatment plan, including services under an IEP I. services provided by family or household members J. care primarily custodial in nature and not requir ing trained/professional ABA staff K. shadowing, para-professional, or companion services in any setting L. personal training or life coaching M. services more costly than an alternative service(s), which are as likely to produce equivalent diagnostic or therapeutic results for the member N. any program or service performed in nonconventional settings, even if performed by a licensed provider ( eg, spas/resorts, vocational or recreational settings, Outward Bound, wilderness, camp or ranch programs) E. Conditions Of CoverageI. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepayment review. Program Integrity will be engaged for an annual review of data. II. When a member has other insurance, Medicaid is always the pay er of last resort.CareSource will not pay more than the Medicaid rate totals for service. Primary payer must provide evidence of determinations for consideration of Medicaid coverage for services. Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.14 III. CareSource reserves the right to request supervision documentation, particularly related to telehealth services.IV. Providers cannot submit multiple dates of service on a single claim line. Each claim line must be specific to a single date of service and the units provided on that single date of service.V. CareSource complies with the Centers for Medicare and Medicaid Services (CMS)medically unlikely edit (MUE) table. If CMS updates the MUE list, the update will take precedence over this policy. The following applies to ABA CPTs: CPT Max imum Unit s Allowed 97151 32 97152 16 97153 32 97154 18 97155 24 97156 16 97157 16 97158 16 0362T 16 0373T 32 VI. Treatment codes are based on daily total units of service in 15-minute increments. A unit of time is att ained when the mid-point is passed. The following are time interval examples: Unit (s) Number of Minutes 1 unit >8-22 minutes 2 units >23 – 37 minutes 3 units >38 – 52 minutes 4 units >53 – 67 minutes 5 units >68 – 82 minutes 6 units >83 – 97 minutes 7 units >98 – 112 minutes 8 units >113 – 127 minutes VII. ODM allows Mental Health Community Behavioral Health Centers (CBHCs), provider type 84, to render and be reimbursed for ABA services using the service code H0036-Community Psychiatric Supportive Treatment (CPST). CareSource strongly encourages CBHCs to use ABA CPT codes outlined above for billing purposes but does accept H0036 when submitted by an appropriately certified CBHC. Expectations of this policy apply to all ABA services , whether billed using ABA CPTcodes or H0036. F. Related Policies/RulesMedical Necessity Determinations Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.15 G. Review/Revision HistoryDATE ACTIONDate Issued 10/04/2018Date Revised 01/27/2020 01/25/202108/04/202103/30/202201/04/202304/ 12 /202303/13 /202409/25/202410/23/202403/26/2025Added program attributes, definitions of provider types and ABA ; title change ; clarified PAd services ; changed NP to healthcare provider trained in ASD ; added IV , willingness to participate , description of p oc, ages ; clarified provider requirements ; added ASD diagnosis, home school /IEP, doc requirements, type of ASD treatment program with PA ; revised continuation of A BA therapy requirements . Added AFLS, ESDM and PEAK-DT assessments & section on ABA transition to school , revised discontinuation criteria & exclusions; removed PA checklist. Clarified telehealt h, moved doc requirements to Medical Records Doc for Practitioners ; re moved transition to school section ; updated school section & RBT supervision ; u pdated definitions & ABA criteria. Removed PA language. III.B.1. Primary diagnosis by a qualified practitioner. Added to section 5. F.02: Removed old section M. to sec. DIII 5.g. added ABA services must include parent/family training . Edited Sec. V. Removed VII. A E-voted ODM changes Sec. B. 1 and 2 Consolidated information into Sec. IV. Initial ABA Treatment Plan. Added Sec. V.J. Pare nt/Caregiver Involvement. Updated references. Reorganized policy & updated definitions. Removed 1:1 telehealth ABA exclusion. Removed I under Exclusions . Annual review. Added VII-X. Merged AD policy info to Cond of Coverage section. Updated H. Approved at Committee. Out of cycle review. Adde d backgroun d, D.I.D, IX.E., E.IV. Updated references. Approved at Committee . Out of cycle review. Removed parent signature as requirement per ODM. Approved at Committee. Removed VII. A.3. and B.7. Approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. 2024 Q2 NCCI MUE Edits-Practitioner Services . Centers for Medicare and Medicaid Services. Accessed September 16 , 2024. www.cms.gov 2. Additional Medicaid Waiver Components for Home and Community-Based Services, OHIO REV . CODE 5166.20 (2016). 3. Anglim M, Conway EV, Barry M, et al. An initial examination of the psychometric properties of the Diagnostic Instrument for Social and Communication Disorders (DISCO-11) in a clinical sample of children with a diagnosis of autism spectrum disorder. Ir JPsychol Med . 2022;39(3):251-260. doi:10.1017/ipm.2020.100 4. Applied Behavior Analysis: B-806-T. MCG. 2 8th ed. Updated March 14 , 202 4. Accessed September 16 , 2024. www.careweb.careguidelines.com 5. Augustyn M. Autism spectrum disorder in children an d adolescents: evaluation and diagnosis. Up ToDate. Updated May 16, 2022. Accessed September 16, 2024 . www.uptodate.com Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.16 6. Augustyn M. Autism spectrum disorder (ASD) in children and adolescents: terminology, epidemiology, and pathogenesis. Up ToDate. Updated January 24,2024. Accessed September 16, 2024 . www.uptodate.com 7. Augustyn M, Von Hahn E. Autism spectrum disorder in children and and adolescents: clinical features. Up ToDate. Updated May 17, 2023. Accessed September 16, 2024 . www.uptodate.com 8. Autism spectrum disorder. American Academy of Pediatrics . Updated April 5, 2023. Accessed September 16, 2024 . www.aap.org 9. Autism spectrum disorder in young children: screening. U.S. Preventive Services Task Force; 2016. Accessed September 16 , 2024. www.uspreventiveservicestaskforce.org 10. Autism Spectrum Disorders: M-7075. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 11. Autism Spectrum Disorders: B-012-HC. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 12. Autism Spectrum Disorders, Adult, Inpatient Care: B-012-IP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 13. Autism Spectrum Disorders, Child or Adolescent: B-019-IP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 14. Autism Spectrum Disorders, Intensive Outpatient Program: B-012-IOP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 15. Autism Spectrum Disorders, Outpatient Care: B-012-AOP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 16. Autism Spectrum Disorders, Partial Hospitalization Program: B-012-PHP. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 17. Autism Spectrum Disorders, Residential Care: B-012-RES. MCG. 28th ed. Updated March 14, 2024 . Accessed September 16 , 2024. www.careweb.careguidelines.com 18. BACB Newsletter . Behavior Analyst Certfication Board; September 2023. Accessed September 16, 2024 . www.bacb.com 19. BACB Newsletter: Introducing the 2026 RBT Examination and Certification Requirements . Behavior Analyst Certification Board; December 2023. Accessed September 16, 2024 . www.bacb.com 20. Bak M, Plavnick J, Dueas A, et al. The use of automated data collection in applied behavior analytic research: a systematic review. Behavior Analysis: Res Practice. 2021;21(4), 376 405. https://doi.org/10.1037/bar0000228 21. Board Certified Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed September 16 , 2024. www.bacb.com 22. Board Certified Assistant Behavior Analyst Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed September 16 , 2024. www.bacb.com 23. Buckley A, Hirtz D, Oskoui M, et al; Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Practice guideline: treatment for insomnia an d disrupted sleep behavior in children and Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.17 adolescents with autism spectrum disorder. Neurology . 2020;94(9):392-404. doi:10.1212/WNL0000000000009033 24. Certified Ohio behavior analyst supervision. State of Ohio Board of Psychology. Accessed September 16, 2024 . www.psychology.ohio.gov 25. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems , I: common clinical challenges of patients with mental health or behavioral emergencies. Pediatr. 2016;138(3):e20161570. doi:10.1542/peds.2016-1570 26. Chun T, Mace S, Katz E; American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Evaluation and management of children and adolescents with acute mental health or behavioral health problems , II: recognition of clinically challenging mental health related conditions presenting with medical or uncertain symptoms. Pediatr. 2016;138(3):e20161573. doi:10.1542/peds.2016-1573 27. Coverage for Autism Spectrum Disorder, OHIO REV . CODE 1751.84 (2021). 28. Crockett, JL, Fleming RK, Doepke K, et al. Parent training: acquisition and gene ralization of discrete trials teaching skills with parents of children with autism. Res Dev Disabilities . 2007; 28 (1):23-36. doi :10.1016/j.ridd.2005.10.003 29. Ethics Code for Behavior Analysts . Behavior Analyst Certification Board; 2020. Updated January 1, 2023. Accessed September 16 , 2024. www.bacb.com 30. Evidence Analysis Research Brief: Applied Behavior Analysis Training Via Telehealth for Caregivers of Children with Autism Spectrum Disorder . Hayes; 2022. Accessed September 16 , 2024. www.evidence.hayesinc.com 31. Evidence Analysis Research Brief: Direct-To-Patient Applied Behavior Analysis Telehealth for Children with Autism Spectrum Disorder . Hayes; 2022. Accessed September 16 , 2024. www.evidence.hayesinc.com 32. Gonzlez MC, Vsquez M, Hernndez-Chvez M. Autism spectrum disorder: clinical diagnosis and ADOS Test. Rev Chil Pediatr . 2019;90(5):485-491. doi:10.32641/rchped.v90i5.872 33. Health Technology Assessment: Comparative Effectiveness Review of Intensive Behavioral Intervention for Treatment of Autism Spectrum Disorder . Hayes; 2019. Updated February 10, 2022. Accessed September 16 , 2024. www.evidence.hayesinc.com 34. Hyman S, Levy S, Myers S ; Council on Children with Disabilities. Developmental and behavioral pediatrics : identification, evaluation, and management of children with autism spectrum disorder . Pediatr . 2020 ;145(1) :e20193447 . d oi:10.1542/peds.2019 – 3447 35. Information on autism spectrum disorder for healthcare providers. Centers for Disease Control and Prevention (CDC). Updated December 6, 2022. Accessed September 16 , 2024. www.cdc.gov 36. Lebersfeld JB, Swanson M, Clesi CD, et al. Systematic review and meta-analysis of the clinical utility of the ADOS-2 and the ADI-R in diagnosing autism spectrum Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.18 disorders in children. JAutism Dev Disord . 2021;51(11):4101-4114. doi:10.1007/s10803-020-04839-z 37. Lefort-Besnard J, Vogeley K, Schilbach L, et al. Patterns of autism symptoms: hidden structure in the ADOS and ADI-R instruments. Transl Psychiatry . 2020;10(1):257. doi:10.1038/s41398-020-00946-8 38. Lim N, Russell-George A. Home-based early behavioral interventions for young children with autism spectrum disorder. Clin Psycho l. 2022;29(4):415-416. doi:10.1037/cps0000117 39. Registered Behavior Technician Handbook . Behavior Analyst Certification Board. Updated December 2023. Accessed September 16 , 2024. www.bacb.com 40. Medicare Claims Processing Manual. Centers for Medicare and Medicaid Services; 2024. Publication # 100-04 . Accessed September 16 , 2024. www.cms.gov 41. Sneed L, Little S, Akin-Little A. Evaluating the effectiveness of two models of applied behavior analysis in a community-based setting for children with autism spectrum disorder. Behav Anal: Res Pract . 2023;23(4):238-253. doi:10.1037/bar0000277 42. Society guideline links: autism spectrum disorder. Up ToDate. Accessed September 16 , 2024. www.uptodate.com 43. Standards for Telehealth Services, OHIO REV . CODE 4743.09 (2023). 44. State Board of Psychology-Certified Ohio Behavior Analysts, OHIO ADMIN . CODE 4783-1 to 11 (2023). 45. Volkmar F, Siegel M, Woodbury-Smith M, et al.; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. JAm Acad Child Adolesc Psychiatry . 2014;53(2):237-57. doi:10.1016/j.jaac.2013.10.013 46. Weissman L. Autism spectrum disorders in children and adolescents: behavioral and educational interventions . Up ToDate. Updated December 4, 2023. Access ed September 16 , 2024. www.uptodate.com 47. Weissman L. Autism spectrum disorder in children and adolescents: overview of management. Up ToDate. Updated September 8, 2023. Accessed September 16 , 2024. www.uptodate.com 48. Weissman L. Autism spectrum disorder in children and adolescents: pharmacologic interventions. Up ToDate. Updated May 30, 2024 . Accessed September 16 , 2024. www.uptodate.com 49. Weissman L. Autism spectrum disorder in children and adolescents: screening tools. Up ToDate. Updated January 24, 2024. Accessed September 16 , 2024. www.uptodate.com 50. Weissman L. Autism spectrum disorder in children and adolescents: surveillance and screening in primary care. Up ToDate. Updated May 5, 2022. Accessed September 16 , 2024. www.uptodate.com 51. Weissman L, Harris H. Autism spectrum disorder in children and adolescents: complementary and alternative therapies. Up ToDate. Updated June 20, 2022. Accessed September 16 , 2024. www.uptodate.com 52. Wergeland J, Posserud M, Fjermestad K, et al. Early behavioral interventions for children and adolescents with autism spectrum disorder in routine clinical care: a Applied Behavior Analysis for Autism Spectrum Disorder-OH MCD-MM-0028 Effective Dat e: 07/01/2025 The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.19 systematic review and metaanalysis. Clin Psycho l. 2022;29(4):400-414. doi:10.1037/cps0000106 53. Witwer A, Walton K, Held M. Taking an evidence-based child-and family-centered perspective on early autism intervention. Clin Psychol . 2022;29(4):420-422. doi:10.1037/cps0000122 Approved by Ohio Department of Medicaid 04/01/2025

Mechanical Stretching Devices

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Mechanical Stretching Devices-OH MCD-MM-1225 07/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4Mechanical Stretching Devices-OH MCD-MM-1225 Effective Date: 07/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Mechanical Stretching Devices B. Background Mechanical stretching devices are intended to restore range of motion (ROM) for joint stiffness or contracture by stretching joints. These devices provide passive stretching to an adjustable degree for a selected duration for multiple sessions. A variety of mechanical stretching devices are available for extension or flexion of the shoulder, elbow, wrist, fingers, knee, ankle, and toes. These devices can provide stretching for longer periods than a physical therapist and are generally used as adjunct treatm ent to physical therapy and/or exercise. Mechanical Stretching Devices (also known as dynamic splinting systems) include: Low-load prolonged duration stretch devices (LLPS) Static progressive stretch (SPS) splint devices Patient actuated serial stretch (PASS) devices C. DefinitionsLow-L oad Prolonged Duration Stretch Devices (LLPS) These devices permit resisted active and passive motion (elastic traction) within a limited range. LLPS devices maintain a set level of tension by means of incorporated rubber bands or springs. Patient Actuated Serial Stretch (PASS) Devices These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction). This type of device itself does not exert a stress on the tissue unless the joint angle is set at the maximum ROM . Static Progressive Stretch Devices (SP S) These devices hold the joint in a set position but allow for manual modification of the joint angle and may allow for active motion without resistance (inelastic traction) . D. Policy I. CareSource considers dynamic splinting devices medically necessary durable medical equipment (DME) as an adjunct treatment to physical therapy, massage, and/or exercise for an existing joint contracture when the following clinical criteria is met: A. m edically necessary only for the following joints: knee, elbow, wrist, finger , ankle and toe B. after 3 weeks of exercise and skilled therapy in the initial subacute injury or post-operative period in members with: 1. signs and symptoms of persistent joint stiffness or contracture 2. limited range of motion that poses a meaningful functional limitation as judged by a physician C. m ay be used for an initial period of 4 weeks , a subsequent 4-week period with reevaluation, and then up to 4 months based on continued improvement . Mechanical Stretching Devices-OH MCD-MM-1225 Effective Date: 07/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.3II. In the acute post-operative period for members who have undergone additional surgery to improve the range of motion of a previously affected joint , CareSource considers use of an LLPS device medically necessary for : A. an initial four-week period B. an additional four-week period, if improvement was noted after the initial four weeks, for up to 4 months . III. Non-C overed Services A. CareSource considers the use of dynamic splinting experimental and investigational for the following indications, including but not limited to: 1. adhesive capsulitis 2. carpal tunnel syndrome 3. cerebral palsy 4. foot drop associated with neuromuscular diseases, 5. hallux valgus 6. head and spinal cord injuries 7. improvement of outcomes following botulinum toxin injection for treatment of limb spasticity 8. injuries of the ankle and shoulder 9. multiple sclerosis 10. muscular dystrophy 11. plantar fasciitis 12. rheumatoid arthritis 13. stroke 14. trismus B. CareSource considers the following devices experimental and investigational due to insufficient scientific evidence of efficacy: 1. patient Actuated Serial Stretch (PASS) devices (for example, ERMI Knee Extensionater and ERMI Shoulder Extensionater) 2. static Progressive Stretch devices (SPS) (for example, Joint Active Systems (JAS) splints (for example, JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and JAS Pronation-Supination)E. Conditions of CoverageAll claims for LLPS are subject to post-payment review by CareSource. F. Related Policies/Rules NA Mechanical Stretching Devices-OH MCD-MM-1225 Effective Date: 07/01/2025 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.4G. Review/Revision History DATE ACTIONDate Issued 11/09/2023 New PolicyDate Revised 02/15/2023 06/07/2023 05/22/2024 03/12/2025e-voted addition of ankle and toe to policy to match fee schedule and MCG. Annual review. Added examples of PASS and SPS devices. Annual review. Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. Furia JP, Willis FB, Shanmugam R, et al. Systematic review of contracture reduction in the lower extremity with dynamic splinting. Adv Ther . 2013;30(8):763-770. Accessed January 26, 2025. www.ncbi.nlm.nih.gov 2. Dynamic Joint Extension and Flexion Devices: ACG A-0882. MCG. 28th ed. 2024. Accessed January 26, 2025. www.careweb.careguidelines.com 3. Glasgow C, Tooth LR, Fleming J, et al. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution predictors of contracture resolution. JHand Ther . Accessed January 26, 2025. www.jhandtherapy.org 4. Harvey LA, Katalinic OM, Herbert RD, et al. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews. 2017. Accessed January 6, 2025. www.pubmed.ncbi.nlm.nih.gov 5. Medical Technology Directory. Mechanical Stretching Devices for the Treatment of Joint Contractures of the Extremities. Hayes , Inc. 2022. Accessed January 26, 2025. www.hayesinc.com 6. Jongs RA, Harvey LA, Gwinn T, et al. Dynamic splints do not reduce contracture following distal radial fracture: a randomised controlled trial. JPhysiother . 2012;58(3):173-180. Accessed January 26, 2025. www.reader.elsevier.com 7. Zatarain LA, Smith DK, Deng J, et al. A randomized feasibility trial to evaluate use of the jaw dynasplint to prevent trismus in patients with head and neck cancer receiving primary or adjuvant radiation-based therapy. Integr Cancer Ther . 2018. I nde pendent med ica l rev iew 12/21Approved by ODM 03/20/2025

Metabolic and Bariatric Surgery-Revision

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Metabolic and Bariatric Surgery-Revision-OH MCD-MM-1061 06/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Polic ies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Metabolic and Bariatric Surgery-Revision-OH MCD-MM-1061 Effective Date: 06/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Metabolic and Bariatric Surgery: Revision B. Background Revision procedures are typically done because of complications from or a failure of the initial surgical procedure. Complications may include surgical or anatomical complications, as well as nutritional or metabolic complications. A failure of the initial bariatric surgery may result in an inadequate weight loss or a weight regain. C. Definitions Revisional Bariatric Surgery (RBS) surgery to address those patients whose original operation was unsuccessful in achieving satisfactory weight loss goals, or in whom complications from the original operation have occurred . Inadequate Weight Loss Less than 50% expected weight loss and/or weight remains greater than 40% over ideal body weight (normal body weight BMI parameter = 18.5-24.9). D. Policy I. CareSource considers surgical revision of a bariatric surgery procedure a covered service when medically necessary. II. An inadequate weight loss due only to non-compliance with dietary , behavior, or exercise recommendations is not a medically necessary indication for a revision procedure . III. A revision procedure is medically necessary when all of the following criteria are met and documented in the medical record: A. surgery/procedure selected is a proven procedure and not considered experimental/investigational and B. a technical failure or major complication has occurred from the initial procedure that cannot be managed medically. Technical failure and major complication examples include the following: 1. persistent pain and recurrent bleeding occur 2. chronic stenosis remains after multiple dilations 3. faulty component or malfunction that cannot be repaired 4. candy cane roux syndrome 5. complications that cannot be corrected with band manipulation, adjustments or replacement including band slippage and port leakage or a. obstruction confirmed by imaging studies . NOTE: Stretching of a stomach pouch formed by a previous bariatric surgery due to overeating is not considered a complication and therefore is not considered an indication for revision . Metabolic and Bariatric Surgery-Revision-OH MCD-MM-1061 Effective Date: 06/01/2025 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.3IV. In the absence of a technical failure or major complication, individuals with weight loss failure 2 years following the initial bariatric surgery procedure must meet medical necessity requirements in the medical policy that applies to an initial bariatric surgery. V. CareSource does not consider endoscopic bariatric and metabolic therapies such as Intragastric balloon (IGB) , e ndoscopic sleeve gastroplasty (ESG), or aspiration therapy (AT) to be weight loss surgery. Individuals with weight loss failure from prior endoscopic therapies must meet medical necessity requirements in the medical policy that applies to an initial bariatric surgery. E. Conditions of Coverage N/A F. Related Polic ies/Rules Medical Necessity Determinations Metabolic and Bariatric Surgery Experimental and Investigational Item or Service G. Review/Revision History DATE ACTIONDate Issued 07/22/2020 New policy Separated out from adolescent and adult policies Date Revised 06/23/2021 06/22/2022 06/21/2023 06/19/2024 02/26/2025PA language replaced by medical necessity criteria. PA enforced by inclusion on the PA list. Updated references. Re-wording of section IV re: medical necessity for revision bariatric surgery. Sec. V. Added IGB, ESG and AT non-coverage. Updated references. Annual review; no changes, Updated references, Approved at committee. Added definition of Revisional bariatric surgery (RBS) . Updated references. Approved at Committee. Updated references. Approved at Committee. Date Effective 06/01/2025 Date Archived H. References1. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federal for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(12):1345-1356. Accessed January 14, 2025. www.soard.org 2. Ellsmere J. Bariatric operations: late complications with subacute presentations. Updated July 18, 2023. Accessed January 17, 2025. www.uptodate.com Metabolic and Bariatric Surgery-Revision-OH MCD-MM-1061 Effective Date: 06/01/2025 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.43. Gastric Restrictive Procedure with Gastric Bypass (S-512). MCG. 28th ed. 2024. Accessed January 14, 2025. www.careweb.careguidelines.com 4. Mechanisk J, Apovian C, et al. Clinical practice Guidelines for the Perioperative Nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures 2020 Update: Cosponsored by American Association of Clinical Endocrinologist/American college of Endocrinology, The obesity society, American Society for metabolic & Bariatric surgery, Obesity medicine Association, and American Society of Anesthesiologists. Obesity . 2020;28(4):01-58. doi:10.1002/oby.22719 5. Palep J. Reoperative bariatric surgery. Recent Advances in Minimal Access Surgery . JP Medical Ltd; 2019:14-151. 6. Weight-Loss and Weight-Management Devices . Federal Drug Administration; 2020. Accessed January 17, 2025. www.fda.gov 7. Yung-Chieh Y, Huang C, Tai C. Psychiatric aspects of bariatric surgery. Curr Opin Psychiatry . 2014;27(5):374-379. doi:10.1097/YCO.00000000000000085. Inde pendent med ica l r e view 7/2020 Approved by ODM 3/13/2025

Adaptive Seating for Special Needs

MEDICAL POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Adaptive Seating for Special Needs-OH MCD-MM-1718 05/01/2025 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standard s, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area , are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manua ls, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Polic y Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.2 A. SubjectAdaptive Seating for Special Needs B. BackgroundCerebral palsy, developmental delays, Down syndrome , and other health conditions may compromise an individuals ability to maintain a sitting posture , muscle tone, and movement . Depending on the severity and type of health condition, individuals may require support for the head, trunk, pelvis, and legs limit ing the ability to interact with others, eat, dress, work, and play. In addition, the se individuals may lack the stability and strength for mobility or transfers. Adaptive seating systems (AdSS) may be used by individuals to achieve and hold anupright sitting position , enabl ing individuals to engage with others and conduct activities of daily living. AdSS can be individualized to meet the unique needs of the person with accessories that allow for the seats to tilt, adjust seat height, increase posture support, transfers, and for limited mobility in the local environment . C. Definitions Adaptive Desks Generally considered furniture and used to support physical and educational needs in a school setting. Adaptive Seating Systems (AdSSs) Equipment designed to improve safety, efficiency of movement , and optimize positioning while promoting active participation in daily activities . There are 2 types : o Activity Chairs Seats that o ptimiz e positioning (eg, adaptive chairs, special needs chairs, pediatric positioning chairs, sitters, and therapy chairs ). o High-Low Chairs Height adjustable seats that secure the individual at the midline with adjustable trunk support, shoulder straps, and hip belts. Adaptive Strollers Strollers with increased seating and positioning options than a basic stroller . D. PolicyI. Adaptive Seating Systems (AdSS) and Accessories A. Adaptive Seating Systems A review of medical necessity must occur prior to purchase/delivery of the item. CareSource considers AdSS medically necessary when ALL the following clinical criteria are met: 1. A prescription valid for 1 year is written by any of the following providers with an established relationship with the member and appropriate certifications or training after document ing a completed face-to-face encounter : a. physician b. advanced practice registered nurse c. physician assistant Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.3 2. Documentation that the member cannot safely sit in conventional seating due to a medical condition, modifications to the members current seating equipment cannot meet their needs, and at least 1 of the following criteria: a. significant head and/or trunk instability or weakness with decreased motor control b. requires external support to maintain an upright position and proper body alignment c. has no functional protective or righting reaction d. must be in an upright su pported position for safe and effective feeding and would otherwise have to be held by the caregiver for feeding e. severe seizure activity f. orthopedic condition resulting in significant bony fragility or significant fracture 3. A physical therap ist (PT) or occupational therapist (OT) experienced in an appropriate specialty and independent from the equipment vendor completed an evaluation and documented that the member can benefit from and safely use the item requested. 4. An y person-centered service plans for the member, when applicable, must list use of AdSS. 5. A complete description of the item requested, including: a. manufacturer b. model of style c. size d. all bundled components e. any accessories or not-included components f. any itemization of all charges B. Accessories 1. Accessorie s are considered medically necessary when they provide additional functional support than is offered by a chair alone and any of the following criteria are met : a. cannot maintain head control in an upright position b. unable to perform a functional weight shift requiring relief to prevent pressure injuries c. needs additional trunk support that is not provided by the chair alone d. changes in muscle tone affecting body tilt or needs additional support for proper digestion or avoidance of severe gastro esophageal reflux e. needed for independent movement in and out of the chair or repositioning the chair to complete daily activities II. Exclusions and LimitationsA. AdSS does not include ANY of the following: 1. adaptive desks 2. adaptive strollers 3. any items not meeting the medical necessity criteria in this policy Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.4 B. Duplicative equipment is excluded. Equipment with the same function as an existing AdSS will not be reviewed for medical necessity. C. AdSS must be the lowest cost alternative that addresses the members health condition. D. AdSS is for the benefit of the member and not for any caregiver, family member, or provider convenience. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 12/04/2024 New policy. Approved at Committee.Date Revised Date Effective 05/01/2025 Date Archived H. References1. Angsupaisal M, Maathuis CGB, Hadders-Algra M. Adaptive seating systems in children with severe cerebral palsy across International Classification of Functioning, Disability, and Health for children and youth version domains: a systematic review. Dev Med Child Neurol . 2015;57(10):919-930. doi:10.1111/dmcn.12762 2. Barkoudah E, Whitaker A. Cerebral palsy: treatment of spasticity, dystonia, and associated orthopedic issues. UpToDate. Updated Nov 17, 2023. Accessed January 3, 2025 . www.uptodate.com 3. Hale LW, Martin C. Autism spectrum disorder in children and adolescents: behavioral and educational interventions. UpToDate. Updated October 22, 2024. Accessed January 3, 2025 . www.uptodate.com 4. Inthachom R, Prasertsukdee S, Ryan SE, et al. Evaluation of the multidimensional effects of adaptive seating interventions for young children with non-ambulatory cerebral palsy. Disabil Rehabil Assist Technol . 2021;16(7):780-788. doi:10.1080/17483107.2020.1731613 5. Khan I, Leventhal BL. Developmental Delay . StatPearls Publishing; 2023. Accessed January 3, 2025 . www.ncbi.nlm.nih.gov 6. Lyman J. Complex rehabilitation fact sheet. Cerebral Palsy Foundation. Published August 16, 2022. Accessed January 3, 2025 . cpresource.org 7. Paleg G, Livingstone R, Rodby-Bousquet E, et al. Care Pathways central hypotonia. American Academy of Cerebral Palsy and Developmental Medicine. Accessed January 3, 2025 , 2024. www.aacpdm.org Adaptive Seating for Special Needs-OH MCD-MM-1718Effective Dat e: 05/01/2025The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.5 8. Provider recommendations for FY 2024 budget medical care advisory committee meeting June 2022. National Council for Assistive & Rehab Technology. Accessed January 3, 2025 , 2024. www.ncart.us9. Ryan SE. Lessons learned from studying the functional impact of adaptive seating interventions for children with cerebral palsy. Dev Med Child Neurol . 2016;58 (Suppl 4):78-82. doi:10.1111/dmcn.13046 10. Saihinoglu D, Coskun G, Bek N. Effects of different seating equipment on postural cont rol and upper extremity function in children with cerebral palsy. Prosthet Orthot Int . 2017;41(1):85-94. doi:10.1177/0309364616637490 Independent medical review December 2024ODM approved 1/23/2025

© Copyright CareSource 2026. All rights reserved.

System Details