Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) Diagnosis

This policy covers Applied Behavior Analysis (ABA) services—including assessments, early intensive behavioral intervention (EIBI), and treatment planning—for members with a DSM‑5 diagnosis of Autism Spectrum Disorder (ASD) when ABA is included in the member’s benefit plan or required by state law. Coverage requires a recent (initial or updated within 36 months) formal diagnostic evaluation recommending ABA, documented clinically significant skill or behavioral deficits (e.g., ≥2 SD below the mean), informed consent and active caregiver participation, a formal plan supervised by licensed/credentialed behavior analysts, and appropriate safety protocols; services are not indicated if out‑of‑home placement is required or the member cannot actively participate. Coverage is governed by the member’s benefit contract and state-specific limits or mandates (Illinois provides an exception for certain children with specified neuromuscular, neurological, or cognitive impairments).