Applied Behavior Analysis

Number: 0554

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses applied behavior analysis.

1. Experimental, Investigational, or Unproven

   Aetna considers applied behavior analysis (ABA) experimental, investigational, or unproven for the following indications because there is insufficient evidence in the peer-reviewed literature to support its effectiveness:

   1. Down Syndrome in the absence of an autism spectrum disorder (ASD) co-morbidity;
   2. All other non-ASD indications.

2. Related Policies

   • CPB 0648 - Autism Spectrum Disorders - for Applied Behavior Analysis for autism

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes not covered for indications listed in the CPB:
97151 - 97158	Adaptive Behavior Assessments and treatment
Other CPT codes related to the CPB::
0362T	Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior
0373T	Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior
ICD-10 codes covered if selection criteria are met :
F84.0 - F84.9	Pervasive developmental disorders [autistic spectrum disorder (ASD)]
ICD-10 codes not covered for indications listed in the CPB:
Q90.0 - Q90.9	Down syndrome

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Background

Applied behavior analysis (ABA) is a structured intervention grounded in the science of learning and operant conditioning, in which observable behaviors are systematically analyzed in relation to environmental antecedents and consequences to achieve socially meaningful change (AHRQ, 2025; Nickerson, 2025). ABA employs empirically derived principles, such as positive reinforcement, shaping, and extinction, to increase adaptive behaviors and decrease maladaptive behaviors, with treatment plans individualized based on functional behavioral assessment and ongoing data collection (CASP, 2024; Nickerson, 2025). It is most commonly utilized for individuals with autism spectrum disorder (ASD), where early and intensive behavioral interventions are a core component of treatment (AHRQ, 2025). Systematic reviews and meta-analyses of randomized and quasi-experimental studies have shown that ABA-based interventions improve outcomes in areas such as communication, socialization, and cognitive functioning, although results vary by outcome measure and study quality (Chung et al., 2024; Han et al., 2025; Makrygianni et al., 2018; Pruneti et al., 2024). Contemporary clinical practice guidelines indicate that ABA is supported by a substantial body of peer-reviewed research, including replicated studies, when delivered with clearly defined, measurable targets and individualized treatment parameters, while emphasizing the need for ongoing assessment and recognition of variability in response (CASP, 2024).

ABA is the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior. The goal is to demonstrate that the interventions used are responsible for the observable improvement in behavior. These methods increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. The focus of ABA is on the reliable measurement and objective evaluation of observable behavior within relevant settings including the home, school, and community and the effectiveness of this intervention has been well documented through research in controlled studies of comprehensive early intensive behavioral intervention programs. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. When correctly designed, implemented and monitored, it is safe and effective for some individuals with ASD. ABA involves the use of behavioral principles (such as positive reinforcement, or the use of rewards) to encourage the development of the desired behaviors in place of the less adaptive, self-defeating or even harmful behaviors the child may be using. Given that children with ASD may also have a level of intellectual disability or deficits in communication, progress may be slow and require much practice, repetition and time to be learned by the child, potentially making this hugely expensive. There are a number of different methodologies and protocols (particularly related to how many hours of treatment are appropriate per week) consistent with ABA, resulting in ambiguity and suspicion about the term. There tends to be a high level of parental satisfaction with such programs that typically involve the parents in reinforcing the behaviors being targeted (Myers, 2007).

Warren et al. (2011) noted that early intensive behavioral and developmental interventions for young children with ASDs may enhance developmental outcomes. Thus, they conducted a systematically review of evidence regarding such interventions for children aged 12 years and younger with ASDs. These researchers retrieved 34 unique studies that met inclusion criteria, of which 17 studies were case series and 2 were randomized controlled trials (RCTs). The investigators reported that the strength of the evidence overall ranged from insufficient to low. Studies of University of California Los Angeles/Lovaas-based interventions and variants reported clinically significant gains in language and cognitive skills in some children, as did 1 RCT of an early intensive developmental intervention approach (the Early Start Denver Model), while specific parent-training approaches yielded gains in short-term language function and some challenging behaviors. The authors concluded that data suggested that subgroups of children displayed more prominent gains across studies, but participant characteristics associated with greater gains are not well understood and that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvements in cognitive performance, language skills, and adaptive behavior skills in some young children with ASDs, although the literature is limited by methodologic concerns.

Weitlauf et al. (2014) conducted a systematic review, the results of which included 65 unique studies comprising 48 randomized trials and 17 non-randomized comparative studies (19 good, 39 fair, and 7 poor quality) published since the prior review. The authors reported that the quality of studies improved compared with that reported in the earlier review; however, their assessment of the strength of evidence (SOE) and confidence in the stability of effects of interventions in the face of future research remained low for many intervention/outcome pairs. Early intervention based on high-intensity applied behavior analysis over extended timeframes was associated with improvement in cognitive functioning and language skills (moderate SOE for improvements in both outcomes) relative to community controls in some groups of young children. However. the magnitude of these effects varied across studies, potentially reflecting poorly understood modifying characteristics related to subgroups of children. Investigators noted that early intensive parent training programs modified parenting behaviors during interactions but that data were limited regarding the ability to improve developmental skills beyond language gains for some children (low SOE for positive effects on language). Social skills interventions varied in scope and intensity and showed some positive effects on social behaviors for older children in small studies (low SOE for positive effects on social skills). Studies of play/interaction-based approaches reported that joint attention interventions may demonstrate positive outcomes in preschool-age children with ASD when targeting joint attention skills (moderate SOE).  It was also reported that data on the effects of such interventions in other areas were limited (low SOE for positive effects on play skills, language, social skills). Studies examining the effects of cognitive behavioral therapy on anxiety reported positive results in older children with IQs greater than or equal to 70 (high SOE for improvements in anxiety in this population). The authors concluded that growing evidence base suggested that behavioral interventions can be associated with positive outcomes for children with ASD. Despite improvements in the quality of the included literature, a need remains for studies of interventions across settings and continued improvements in methodologic rigor. They stated that substantial scientific advances are needed to enhance the understanding of which interventions are most effective for specific children with ASD and to isolate elements or components of interventions most associated with effects.

The Behavior Analyst Certification Board (BACB, 2014) issued a clarification to supplement prior guidance from "Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.)", with emphasis on informing healthcare funding and management decisions. This clarification further defined treatment intensity (dosage) as encompassing both the number of hours of direct applied behavior analysis (ABA) services delivered per week and the overall duration of treatment, with primary emphasis on weekly direct service hours. Focused ABA treatment was characterized as direct intervention targeting a limited number of behaviors, including functional skills and problem behaviors, with typical intensity ranging from approximately 10 to 25 hours per week, although higher intensity may be warranted based on individualized clinical factors, such as behaviors posing risk to the individual or others. In contrast, comprehensive ABA treatment was described as addressing multiple developmental domains, including cognitive, communicative, social, emotional, and adaptive functioning, in addition to maladaptive behaviors, with intensity levels commonly ranging from 30 to 40 hours per week to address a broader array of treatment targets. The guidance specified that determinations regarding treatment scope (focused versus comprehensive) and intensity should be based on the medical necessity of the individual, rather than age, prior treatment history, or duration of services. Additionally, treatment intensity was defined as services delivered directly to the individual, with the clarification that time allocated to case supervision, caregiver training, school participation, and other concurrent therapies should not reduce authorized hours of direct ABA treatment, as these services are provided in addition to direct intervention.

Kodak and Bergmann (2020) described ASD as a neurodevelopmental disorder characterized by deficits in social communication and social interaction and the presence of restricted, repetitive patterns of behavior, interests, or activities present during early periods of development that negatively impact social, occupational, or other domains. They report that interventions based on principles of ABA can effectively reduce social skills deficits following training. Approaches to language development and communication based on ABA incorporate a functional approach to language and can effectively increase verbal and nonverbal communication skills. Additionally, teaching strategies based on ABA can be used to teach adaptive skills, like daily living  skills, to help individuals with ASD acquire more independence.

In a scoping review, Gitimoghaddam et al. (2022) examined the published literature regarding the effects of applied behavior analysis (ABA) interventions on children and youth with autism spectrum disorder (ASD). The review utilized a scoping design that searched seven electronic databases for peer-reviewed, English-language studies published from January 1, 1997, to December 31, 2020, including randomized controlled trials, clinical controlled trials, and single-case experimental design studies. The population studied comprised children and youth aged 0 to 18 years diagnosed with ASD or mixed diagnoses that included ASD. Outcomes were assessed across eight domains: cognitive, language, social/communication, problem behavior, adaptive behavior, emotional outcomes, autism symptoms, and quality of life (QoL). Out of 2,948 initially identified records, 770 were included in the synthesis, with 551 evaluating the impact of ABA. Improvements were noted in 63% to 88% of the studies across various outcome categories, while only 0% to 2% reported regression, 13% to 36% indicated mixed outcomes, and 0% to 13% showed no change; notably, no studies measured subjective QoL outcomes. Furthermore, only 32 of the 770 records (4%) assessed ABA impact, included a comparison group, and did not rely on mastery of specific skills to indicate improvement. The authors concluded that the literature demonstrated reported improvements across seven of the eight outcome domains and highlighted the necessity for large-scale prospective studies that compare ABA with non-ABA interventions and incorporate measures of subjective QoL to better inform policy decisions.

Eckes et al. (2023) reviewed the effects of comprehensive applied behavior analysis–based interventions in children with ASD using a meta-analytic approach. Their review assessed controlled studies comparing comprehensive ABA-based interventions with treatment as usual, minimal treatment, or no treatment, excluding naturalistic developmental behavioral interventions. The population included children with autism spectrum disorder drawn from 11 controlled studies comprising 632 participants. Outcomes assessed included adaptive behavior, intellectual functioning, language abilities, symptom severity, and parental stress. The review reported that comprehensive ABA-based interventions showed a standardized mean difference of 0.51 (95% CI, 0.09–0.92) for intellectual functioning and 0.37 (95% CI, 0.03–0.70) for adaptive behavior compared with control conditions. Language abilities did not differ between groups (standardized mean difference, 0.30; 95% CI, −0.13 to 0.72). Symptom severity showed no difference between groups (standardized mean difference, −0.26; 95% CI, −0.60 to 0.07). Parental stress also did not differ between intervention and control conditions (standardized mean difference, 0.38; 95% CI, −0.26 to 1.01). The authors concluded that comprehensive ABA-based interventions were associated with improvements in intellectual functioning and adaptive behavior but not with changes in language abilities, symptom severity, or parental stress. The review reported that most included studies had methodological limitations, including high risk of bias, baseline group differences, and variability in control interventions.

Chung et al. (2024) reviewed behavioral and educational interventions for individuals with autism spectrum disorder with a specific focus on applied behavior analysis–based approaches. The review addressed comprehensive treatment models, focused interventions for core and associated symptoms, parent-mediated interventions, and other commonly used non-behavioral approaches across children, adolescents, and adults with autism spectrum disorder. Outcomes assessed across the reviewed literature included intelligence quotient, adaptive behaviors, language, social communication, social skills, sleep, eating behaviors, toileting, emotional difficulties, and challenging behaviors. Six review studies of early intensive behavioral intervention reported consistent improvements in intelligence quotient and adaptive behaviors 12 months after intervention, with reported effect sizes ranging from g=0.42 to 0.74 across language, social interaction, daily communication, and self-help skills, and recommendations of 25–40+ hours per week for 12–24 months were described. Meta-analytic findings for the Early Start Denver Model reported a mean effect size of g=0.357 across developmental outcomes, with cognitive function (g=0.412) and language (g=0.408) showing significant improvements. Focused interventions such as social skills training demonstrated medium to large effect sizes for social skills improvement (g=0.51 to 0.81), and picture exchange communication system interventions showed small to medium effects for speech outcomes. Behavioral sleep interventions were reported to increase sleep time and efficiency and reduce sleep latency, while eating interventions combining contingent reinforcement and non-removal of the spoon showed an improvement rate difference of 0.69 for food intake. Parent-mediated interventions for challenging behaviors were associated with reductions in challenging behaviors (standardized mean difference=0.67) and parenting stress (standardized mean difference=0.37), although reviews noted variability in effects. The authors concluded that early intensive behavioral intervention, naturalistic developmental behavioral interventions, focused behavioral interventions, cognitive behavioral therapy for emotional difficulties, and parent-mediated interventions were supported by varying levels of evidence, while other interventions required further research to establish effectiveness.

Mutschler Collins et al. (2025) conducted a meta-analysis to evaluate the effectiveness of ABA–based interventions, including naturalistic developmental behavioral interventions, for improving communication, adaptive, and cognitive skills and reducing autism spectrum disorder symptom severity in children identified as being on the autism spectrum. The review examined randomized controlled trials and nonrandomized controlled group studies that included pre‑ and post‑intervention comparisons with control groups. The population comprised children with autism spectrum disorder with a mean age at intake between 1.5 and 9.9 years. Outcomes assessed included receptive and expressive language skills, adaptive behavior domains, cognitive skills, and autism symptom severity. Across 25 included studies, ABA‑based interventions demonstrated a large standardized mean change for receptive language skills (SMC = 0.74, 95% CI 0.49–0.99), moderate standardized mean changes for expressive language skills (SMC = 0.48, 95% CI −0.08–1.04), adaptive behavior communication (SMC = 0.63, 95% CI 0.29–0.98), adaptive behavior daily living (SMC = 0.49, 95% CI 0.16–0.81), adaptive behavior socialization (SMC = 0.53, 95% CI 0.25–0.81), adaptive behavior composite (SMC = 0.68, 95% CI 0.36–1.01), and cognitive skills (SMC = 0.65, 95% CI 0.47–0.82), and a small standardized mean change for reduction in autism symptom severity (SMC = −0.30, 95% CI −0.59 to −0.01). Meta‑regression analyses reported that higher treatment dose and longer treatment duration were associated with greater improvements in adaptive behavior outcomes, and younger age at intervention onset was associated with greater improvements in adaptive motor skills. Limitations included variability in study quality, limited reporting of treatment fidelity, supervision, parent outcomes, and follow‑up assessments.

Han et al. (2026) reviewed the quantitative effectiveness and qualitative experiences associated with applied behavior analysis (ABA)–based interventions, including Early Intensive Behavioral Intervention and naturalistic developmental behavioral interventions, for children and adolescents with autism spectrum disorder. The review followed a mixed-methods systematic review and meta-analysis approach using PRISMA guidelines and included 25 studies, comprising 16 randomized controlled trials and 9 qualitative or mixed-methods studies, identified from seven databases searched through August 2023. The quantitative synthesis included 893 participants with autism spectrum disorder, with reported ages ranging from 12 months to 15 years, while qualitative studies included children, parents, and practitioners across home, clinical, educational, and community settings. Outcomes assessed quantitatively included adaptive behavior, daily living skills, socialization, receptive and expressive language skills, joint attention behavior, autism symptom severity, intelligence quotient, developmental quotient, and motor skills. The meta-analysis reported improvements compared with control conditions in adaptive behavior (standardized mean difference [SMD] = 0.31; 95% confidence interval [CI], 0.04–0.59; low-quality evidence), daily living skills (SMD = 0.36; 95% CI, 0.08–0.64; low-quality evidence), language skills (SMD = 0.42; 95% CI, 0.24–0.60; moderate-quality evidence), and joint attention behavior (SMD = 0.27; 95% CI, 0.04–0.49; low-quality evidence). Comparisons with treatment as usual showed effects for adaptive behavior (SMD = 0.34; 95% CI, 0.02–0.66), daily living skills (SMD = 0.39; 95% CI, 0.07–0.71), and language skills (SMD = 0.51; 95% CI, 0.24–0.78). High-intensity interventions demonstrated a larger effect on language outcomes (SMD = 0.72; 95% CI, 0.42–1.01) than low-intensity interventions (SMD = 0.34; 95% CI, 0.13–0.55). The analysis did not demonstrate a statistically significant effect on autism symptom severity (SMD = 0.73; 95% CI, −0.06 to 1.51). Qualitative findings described perceived improvements in child behavior and communication, alongside reported caregiver burden, financial constraints, workforce limitations, and variability in training quality. The authors concluded that ABA-based interventions were associated with improvements in several developmental and functional outcomes, while noting methodological limitations and variability across studies.

When ABA services are provided in conjunction with inpatient, residential, or partial hospitalization care, coverage determinations are based on the medical necessity criteria applicable to the level of care. Separate review of ABA-specific criteria may be performed in the outpatient setting or at the time of transition from a higher level of care, as appropriate.

ABA is generally provided for a defined period, with continuation of services dependent on documentation of measurable improvement in targeted behaviors and functional outcomes.

ABA for Down Syndrome

Applied behavior analysis (ABA) is a behavioral intervention framework based on reinforcement and learning theory that is used to improve adaptive functioning and reduce maladaptive behaviors across developmental conditions. Although ABA is well established for autism spectrum disorder, the evidence base for its use in individuals with Down syndrome is comparatively limited. A 2021 systematic review and meta-analysis of single-case experimental studies (n=125 studies; 36 high-quality) demonstrated a medium overall effect on outcomes such as communication and challenging behaviors; however, the literature is largely composed of single-case designs with significant heterogeneity and lacks robust randomized controlled trials (Neil et al., 2021).

Feeley and Jones (2006) noted that children with Down syndrome are at an increased risk for engaging in challenging behavior that may be part of a behavioral phenotype characteristic of Down syndrome. These investigators stated that the methodology of ABA has been demonstrated effective with a wide range of challenging behaviors, across various disabilities; applications to children with Down syndrome and the examination of behaviorally based strategies to specifically address the unique characteristics of children with Down syndrome were limited. These researchers stated that there were several studies in which a subset of the participants did have Down syndrome, and they reviewed a handful of these studies within the context of functional behavior assessment and positive behavioral supports. Drawing from these studies and the behavioral literature, as well as the authors’ clinical experience and research, they provided suggestions regarding early intervention for challenging behavior with children with Down syndrome.

Kroeger and Nelson (2006) stated that the incidence of children dually diagnosed with Down syndrome and autism is estimated to be as high as 11%. There is a paucity of research investigating linguistic treatment interventions for such children. This single-subject experiment examined a program designed to increase the language production and verbal behavior of a 9-year old dually diagnosed boy who had been receiving a 15 hours/week home-based ABA program. Training principles were derived from previously empirically validated research in discrete trail learning and natural environment teaching, as well as modified incidental teaching procedures. The crux of the language program involved withholding reinforcement until a spoken request was made. Language production noticeably increased for each target area after the introduction of the language program and was maintained at a 9-month follow-up session. The authors concluded that a combined treatment approach incorporating direct instruction, natural environment teaching and incidental teaching could be effective in increasing and maintaining responsive and spontaneous speech in a child with Down syndrome diagnosed with autism. Moreover, they stated that replication studies are needed with such multiple dually diagnosed children to further evaluate the effectiveness and generalizability of this combined language program.

van Gameren-Oosterom et al. (2013) examined problem behavior in adolescents with Down syndrome and evaluated the association with sex and severity of intellectual disability. Cross-sectional data of a Dutch nationwide cohort of Down syndrome children aged 16 to 19 years were collected using a written parental questionnaire. Problem behavior was measured using the Child Behavior Checklist and compared with normative data. The degree of intellectual disability was determined using the Dutch Social competence rating scale. The response rate was 62.8% (322/513), and the mean age was 18.3 years (SD ± 0.8). The total score for problem behavior was higher in adolescents with Down syndrome than in adolescents without Down syndrome (26.8 versus 16.5; p < 0.001). Overall, 51% of adolescents with Down syndrome had problem scores in the clinical or borderline range on 1 or more Child Behavior Checklist subscales; this was more than twice as high as adolescents without Down syndrome.  Adolescents with Down syndrome had more internalizing problems than their counterparts without Down syndrome (14% and 9%, respectively, in the clinical range); the percentages for externalizing problems were almost equal (7% and 9%, respectively, in the clinical range). The highest problem scores in adolescents with Down syndrome were observed on the social problems and thought problems subscales (large to very large standardized differences). Male sex and/or more severe mental disabilities were associated with more behavioral problems. The authors concluded that serious problem behavior was more prevalent in adolescents with Down syndrome; and they stated that these findings demonstrated the need for a focus on general behavior improvement and on the detection and treatment of specific psychopathology in individuals with Down syndrome.

Spinazzi et al. (2023) conducted a single-center retrospective study to investigate the prevalence of medical, neurodevelopmental, and mental health co-occurring conditions in children with Down syndrome and autism spectrum disorder. The study reviewed prospectively and longitudinally collected clinical data from a specialized Down Syndrome Program at a tertiary pediatric medical center between March 2018 and March 2022. The population included 562 individuals aged 3 years or older with confirmed Down syndrome, of whom 72 (13%) had a co-occurring diagnosis of autism spectrum disorder. Outcomes assessed included demographic characteristics, birth history, medical conditions, neurodevelopmental disorders, and mental health conditions, with odds ratios calculated to compare those with Down syndrome and autism spectrum disorder to those with Down syndrome alone. Individuals with both Down syndrome and autism spectrum disorder were more likely to be male (odds ratio 2.23, 95% confidence interval 1.29–3.84) and had higher odds of experiencing constipation (odds ratio 2.19, 95% confidence interval 1.31–3.65), gastroesophageal reflux (odds ratio 1.91, 95% confidence interval 1.14–3.21), behavioral feeding difficulties (odds ratio 2.71, 95% confidence interval 1.02–7.19), infantile spasms (odds ratio 6.03, 95% confidence interval 1.79–20.34), epilepsy (odds ratio 2.70, 95% confidence interval 1.02–7.17), and scoliosis (odds ratio 2.73, 95% confidence interval 1.16–6.40). Conversely, there were lower odds of congenital heart disease in the Down syndrome and autism spectrum disorder group (odds ratio 0.56, 95% confidence interval 0.34–0.93), with no observed differences in prematurity, neonatal intensive care unit complications, congenital heart disease requiring surgery, autoimmune thyroiditis, celiac disease, anxiety disorders, attention-deficit/hyperactivity disorder, or other diagnosed co-occurring neurodevelopmental or mental health conditions. The authors concluded that multiple medical conditions were more frequent in children with Down syndrome and autism spectrum disorder compared to those with Down syndrome alone. However, the authors acknowledged that the study was limited by its single-center design and reliance on caregiver-reported medical history.

Current clinical guidance for Down syndrome does not identify ABA as a standardized or first-line intervention. Therefore, ABA is considered investigational or unproven as a treatment modality due to insufficient high-quality evidence supporting consistent clinical effectiveness.

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References