02-10 8 Applied Behavior Analysis or Lovaas Therapy for Autism

Applied Behavior Analysis (ABA) or Lovaas Therapy for Autism Policy Number: 8.03.500 Origination: 2/2007

Last Review: 2/2010 Next Review: 2/2011

Policy BCBSKC will not provide coverage for applied behavior analysis. This is considered investigational.

When Policy Topic is covered Not Applicable

When Policy Topic is not covered Applied behavior analysis for the treatment of autism is considered investigational.1

Considerations 1 This Blue Cross and Blue Shield of Kansas City policy statement was developed using available resources such as, but not limited to: Hayes Medical Technology Directory, Food and Drug Administration (FDA) approvals, Facts and Comparisons, National specialty guidelines, Local medical policies of other health plans, Medicare (CMS), Local providers.

Description of Procedure or Service Lovaas therapy is an intensive behavioral treatment program that attempts to improve the cognitive and social functioning of children with autism. Autism is a pervasive developmental neuropsychiatric disorder characterized by a range of social and communicative deficits, language-based cognitive deficits, and restricted and repetitive behaviors and interests. Treatments include behavioral, educational, and cognitive therapies that attempt to reduce disruptive behavior and improve communication skills and social adjustment. One type of therapy, referred to as Lovaas therapy, Early Intensive Behavioral Intervention (EIBI), Intensive Behavioral Intervention (IBI), Discrete Trial Training (DTT) or Applied Behavior Analysis (ABA), involves use of operant conditioning, a behavioral modification technique in which a reinforcement, either positive or negative, is used to elicit or control certain behaviors. The operant conditioning is delivered in a highly structured and intensive program, with one-to-one instruction by a trained therapist 25 to 40 hours per week for several years. Parents are usually active participants in the treatment process and are taught to continue the training at home. Intensive behavioral therapy is initiated when a child is young, usually by age 3, and can be administered in a home, school, or clinical setting.

Rationale Evidence evaluated for this report was obtained from a search of the peer-reviewed literature published between 1966 and February 2003. The literature search identified a number of articles describing various kinds of language and behavioral therapy. However, only controlled studies that assessed programs specifically based on Lovaas therapy and that included at least 10 subjects were selected for review. The available studies included the original work by Lovaas and a subsequent long-term follow-up study that compared outcomes in young autistic children who underwent intensive therapy with those in

children who received minimal treatment; however, this study did not randomize subjects to treatment groups. There were also two small, nonrandomized studies comparing intensive therapy with minimal or school-based interventions, and three randomized or incompletely randomized trials, one of which was an early study comparing residential, outpatient, and home-based interventions, and two of which compared Lovaas-based therapy with minimal or eclectic therapy. All of the available studies involved small numbers of children with autism, who were mostly between the ages of 3 and 7 years, although two studies included younger children as well. The original Lovaas study and the long-term follow-up study excluded low-functioning autistic subjects, as did the two most recent randomized trials. Outcome measures used in the various studies included school placement and performance, Intelligence Quotient (IQ) score as measured by the Wechsler Intelligence Scale for Children-Revised, measures of infant and child development, parental assessment of behavior and emotional functioning, psychological evaluation using the Clinical Rating Scale, and clinical assessment using the Autistic Symptom Checklist and Functional Behavior Checklist. Several studies provided relatively long-term follow-up data, in some cases up to 10 years following enrollment in the study. The original study by Lovaas and the follow-up study reported that young autistic children treated with intensive behavioral therapy experienced substantial, durable improvements in behavior, social interaction, and cognitive function, with some able to attend regular classes at school. The investigators also suggested that some of the intensively treated children were essentially cured of autistic symptoms. These reports had a tremendous impact on the field of behavioral therapy and generated considerable enthusiasm for treatment of autistic children with intensive behavioral therapy. However, over the past decade, a number of questions have been raised regarding the Lovaas study, including potential selection bias due to inclusion/exclusion criteria and lack of randomization, the sensitivity of measurement instruments, and the relevance of study endpoints. Similar methodological weaknesses are present in several of the other studies that reported positive effects of the Lovaas therapy. Results of a recent, randomized controlled trial of Lovaas therapy compared with minimal therapy suggest that young children (18 to 42 months of age) with autism or pervasive developmental delay who have an initial IQ score ≥ 35 may achieve significant gains in IQ score, language skills, and other mental abilities, and that some may be able to function in a regular classroom setting after receiving intensive behavioral therapy. However, in this study, the post-therapy mean IQ score of the intensive therapy group still fell within the developmentally disabled range, and there was no significant change in post-therapy behavior or socialization. Moreover, children who received minimal therapy, consisting of parent-administered therapy and special education services, also showed gains in visual-spatial skills and language. Data from a more recent controlled but incompletely randomized study of autistic children who had initial IQ scores ≥ 50 suggest that intensive behavioral therapy based on the Lovaas model may permit greater gains in cognitive and language function than some other forms of therapy, particularly in highfunctioning autistic children. In this study, 25 autistic children between 4 and 7 years of age were assigned by an independent clinician to either intensive behavioral therapy based on the Lovaas model or to eclectic therapy based on a variety of different commonly used methods for treating autistic children. All subjects received at least 20 hours of therapy per week and were evaluated after 1 year. The mean gains in IQ scores, language skills, and composite scores on adaptive behavior scales were significantly greater for children who received intensive behavioral therapy than for those who received eclectic therapy. However, this study did not provide long-term follow-up, it focused primarily on measures of cognitive function rather than social development, and it included only children with a high level of cognitive function on intake. An update completed in May 2006 was performed using Medline with keywords autism or pervasive developmental disorder combined with behavioral therapy, behavior analysis, or Lovaas. Two abstracts were retrieved including a randomized controlled trial and a controlled clinical trial. Efficacy remains unchanged from 2003 Directory Report. Patient selection criteria remains unchanged from 2003 Directory Report. Safety issues remain unchanged from 2003 Directory Report.

Definitive patient selection criteria have not been established for the treatment of autistic children with intensive behavioral therapy. References: 1. Cohen H, Amerine-Dickens M, Smith T. Early intensive behavioral treatment: replication of the UCLA model in a community setting. J Dev Behav Pediatry, 2006 Apr;27(2 Suppl):S145-55. 2. Johnson E, Hastings RP. Facilitating factors and barriers to the implementation of intensive homebased behavioural intervention for young children with autism. Child Care Health Dev. 2002 Mar;28(2):123-9. 3. Lovaas Therapy for Autism. Hayes Inc Online. February 28, 2003, updated May 8, 2007. 4. Oneal BJ, Reeb RN, Korte JR, Butter EJ. Assessment of home-based behavior modification programs for autistic children: reliability and validity of the behavioral summarized evaluation. J Prev Intery Community. 2006;32(1-2):25-39. 5. Sallows GO, Grauper TD. Intesnive behavioral treatment for children with autism: four-year outcome and predictors. Am J Ment Retard. 2005 Nov;110(6):417-38. 6. Shea V. A perspective on the research literature related to early intensive behavioral intervention (Lovaas) for young children with autism. Autism. 2004 Dec;8(4):349-67. 7. Smith T, Buch GA, Gamby TE. Parent-directed, intensive early intervention for children with pervasive developmental disorder. Res Dev Disabil. 2000 Jul-Aug;21(4):297-309. 8. Hayes, Inc. Intensive behavioral intervention therapy for autism. Published April 6, 2008. Updated April 27, 2009.

Billing Coding/Physician Documentation Information 97532

97533

97039

Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes. Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes. Unlisted modality (specify type and time if constant attendance)

A specific code for Lovaas therapy does not exist. The codes listed above may be used.

Additional Policy Key Words Applied Behavior Analysis (ABA) Intensive Behavioral Intervention (IBI) Discrete Trial Training Early Intensive Behavioral Intervention (EIBI) Intensive Intervention Programs

Policy Implementation/Update Information 2/1/07 2/1/08 2/1/09 2/1/10

New policy; considered investigational. No policy statement changes. No policy statement changes. No policy statement changes.

State and Federal mandates and health plan contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The medical policies contained herein are for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care providers are

independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas City and are solely responsible for diagnosis, treatment and medical advice. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, photocopying, or otherwise, without permission from Blue Cross and Blue Shield of Kansas City.