Or. Admin. Code § 410-172-0770 - Individual Eligibility for Applied Behavioral Analysis Treatment

(1) Prior to receiving services, individuals receiving ABA services for the treatment of autism spectrum disorder (ASD) shall have an evaluation by a licensed practitioner, described in OAR 410-172-0760(1) (a-d), experienced in the diagnosis and treatment of autism using the current DSM criteria that includes:

(a) A diagnosis of an ASD listed on the ASD line of the Health Evidence Review Commission's (HERC) Prioritized List;

(b) Documentation of and results from a standardized, validated tool, such as the Autism Diagnostic Observation Schedule (ADOS), that has been used to substantiate the autism disorder;

(c) Documentation of individual core features of autism as identified through a review of ASD diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM 5);

(d) Documentation that a parent or caregiver has been interviewed;

(e) Documentation that there was a review of relevant medical records;

(f) Documentation that the practitioner was able to observe the individual directly;

(g) Documentation of developmental status using validated assessments or a combination of such assessments, such as the Vineland. This information may be provided by a licensed ABA provider;

(h) Documentation of a comprehensive medical exam. A physical exam from the most recent well child care visit may be submitted if within one year for children aged 1-6, or within two years for children 6-18. The physical exam must be completed before starting ABA but may not be allowed to delay or interrupt ABA services;

(i) Documentation that an audiology or hearing test has been performed within one year for children aged 2 through 5, or within two years for children aged 6 through 18. The audiology or hearing test must be completed before starting ABA but may not be allowed to delay or interrupt ABA services;

(A) Newborn assessment is not sufficient after the age of 24 months;

(B) Hearing tests from primary care offices and schools are sufficient if there are no concerns regarding hearing;

(j) Any other documentation, if available, that would substantiate the diagnosis of autism or stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder including but not limited to the following:

(A) Notes from well-child visits or other medical professionals;

(B) Results from any additional assessments including but not limited to IQ, achievement tests, speech and language tests, and assessments of adaptive functioning.

(k) A referral for ABA treatment with or without specification of hours or intensity that shall include:

(A) A diagnosis of ASD or stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder;

(B) A copy of the evaluation described in 410-172-0770(1);

(C) A referral for ABA treatment with or without specification of hours or intensity.

(2) Prior to receiving services, individuals receiving ABA for the treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder shall have an evaluation by a licensed practitioner, practicing within their scope of practice, who has training or experience in the diagnosis and treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder that includes results from a questionnaire or observations that have been used to substantiate the diagnosis.

(3) Prior authorization for intensive and less intensive interventions must be based on an individualized determination of medical appropriateness for each individual and relevant guideline notes from the HERC Prioritized List at the initiation and continuation of ABA services. Services in excess of the HERC Prioritized List coverage guidance or guideline notes shall be provided when medically appropriate for a particular individual, including individuals age 13 and older. Relevant factors to consider when making a prior authorization determination include but are not limited to the following:

(a) Severity;

(b) Depth and breadth of previous treatment;

(c) How recently the diagnosis has been made. For example, if the diagnosis has been made after the child turned 13, intensive treatment shall be considered;

(d) Comorbidities such as psychiatric disorders, developmental delays, and intellectual disability may make it harder to treat ASD and may require more intensity of treatment to be effective;

(e) Factors that would be contrary to the efficacy of ABA or increased intensity of ABA services.

Notes

Or. Admin. Code § 410-172-0770

DMAP 32-2015, f. 6-24-15, cert. ef. 6/26/2015; DMAP 12-2017, f. & cert. ef. 4/4/2017

Stat. Auth.: ORS 413.042, 430.640

Stats. Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705, 430.715