Applied Behavior Analysis (ABA) or Lovaas Therapy for Autism

Policy Number: 8.03.500 Last Review: 2/2010

Origination: 2/2007 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 high-
functioning 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 home-
based 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 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.
97533 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.
97039 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 New policy; considered investigational.
2/1/08 No policy statement changes.
2/1/09 No policy statement changes.
2/1/10 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
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Kansas City.