Medical Policy Update

New Medical Policy

Medical Policy:  I.222 Quantity Limit for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) Services

Effective Date:  11/15/2026
Preauthorization Required: No 

Purpose
To establish clinical and utilization management criteria for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services and to define maximum allowable therapy hours.

Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) are considered medically necessary when prescribed by a qualified healthcare provider and when the services are necessary to improve and restore functional abilities resulting from illness, injury, congenital condition, surgery, or disability.

Limitation on Therapy Hours

Coverage for therapy services is limited to a maximum of 25 hours per week for each therapy discipline:

• Physical Therapy (PT): Up to 25 hours per week
• Occupational Therapy (OT): Up to 25 hours per week
• Speech Therapy (ST): Up to 25 hours per week

The weekly maximum applies independently to each therapy type and is calculated over a seven-day period.

Revised Medical Policies

Medical Policy:  I.178 Autism Spectrum Disorders

Effective Date:  11/15/2026
Preauthorization Required: YES  

Policy Statement:
Please review carefully several changes have been made

Nebraska Revised Statutes, Chapter 44-7, 106 states:

44-7,106. Coverage for screening, diagnosis, and treatment of autism spectrum disorder; requirements.

Behavioral health treatment means counseling and treatment programs, including applied behavior analysis that are:  (i) Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; and (ii)  provided or supervised, either in person or by telehealth (CPT codes 97155 97156 are the only services payable as telehealth), by Licensed Behavior Analyst (LBA) or Board Certified Behavior Analyst (BCBA) or licensed psychologist, if services performed are within the boundaries of the psychologist’s competency.  

1. An initial course of ABA treatment may be considered medically necessary for an individual with ASD when a state mandate requires or a benefit plan explicitly provides coverage for ABA and ALL the following selection criteria are met:
   
   1. diagnosis of Autism has been made by a licensed medical professional or licensed psychologist AND the goals of intervention are appropriate for the individual’s age and impairments with regards to type, frequency, intensity, extent, site and duration of services and a current referral (within 3 years) is on file for ABA services from the treating/ordering physician
      AND
   2. The diagnosis must be supported by ALL the following:
      1. structured parent or caregiver interviews
      2. supported by direct behavioral observations 
      3. social communication and social interaction deficits exhibited in at least 2 different settings 
      4. repetitive or restricted behaviors
      AND
   3. Age 7 and under: Social, communication, or language skills or academic functioning that have been identified as deficient relative to age expected norms, which forms the basis for an individual treatment plan. The treatment plan should include treatment with a certified or licensed ABA provider (in accordance with state law and benefit plan requirements) for no more than 25 hours per week; OR
   4. Age 8 and over:  Behaviors or deficits that are interfering with social, communication or language skills or academic functioning form the basis for an individualized treatment plan; The treatment plan should include treatment with a certified or licensed ABA provider (in accordance with state law and benefit plan requirements) for no more than 25 hours per week; 
   AND
2. Documentation is provided which describes the individual-specific treatment plan that includes ALL the following:
   
   1. Addresses the identified behavioral, psychological, family, and medical concerns; AND
   2. Has measurable goals in objective and measurable terms based on standardized assessments that address the behaviors and impairments for which the interventions are to be applied (NOTE: this should include, for each goal, baseline dates and measurements, progress to date and anticipated timeline for achievement based on both the initial assessment and subsequent interim assessments over the duration of the interventions)  If a patient has been absent from services for more than 60 days, new assessments and goals are required; AND
   3. If group ABA services are requested, there must be documentation that the child is at an age and development level where group therapy will be beneficial and documentation of specific ABA goals to support the hours of group therapy requested AND
   4. Documents that ABA services will be delivered by an appropriate provider who is licensed or certified according to the requirements of applicable state laws and benefit plan requirements.
3. Continuation of ABA treatment may be covered for an individual with ASD when a state mandate requires, or a benefit plan explicitly provides coverage for ABA when the current ABA treatment demonstrates significant improvement on treatment plan goals and progress toward bridging the member’s chronological and developmental age:
   1. The individual has met criteria for an initial course of ABA; AND
   2. Reassessment of services and individual-specific treatment plan is performed and documented every 6 months or as required by a state mandate.   Note: treatment plans may be required more often than every 6 months when warranted by individual circumstances; AND
   3. For each goal in the individual-specific treatment plan, the following is documented:
      1. Significant improvement is: mastery of a minimum of 50 percent of stated goals and/or objectives found in the submitted treatment plan. This is demonstrated through pre- and post- data, including documented generalization of skills developed through goals across people, settings, and environments.
      2. Evidence used to show member progress toward bridging the gap between chronological and developmental ages includes psychological tests. The documentation must show evidence of measurable functional improvement, as opposed to declining or plateaued scores.
      3. For members who do not master 50 percent of stated goals and objectives and/or demonstrate evidence toward bridging the gap between chronological and developmental ages, the treatment plan should clearly address the barriers to treatment success. Psychological testing may be requested to clarify lack of treatment response. If on subsequent reviews the member does not demonstrate significant improvement or progress mastering goals and objectives, and/or progress toward bridging the member’s chronological and developmental ages, coverage of ABA services may be denied through the peer review process.
4. Treatment is required for reasons other than the convenience of the patient, parents/caregiver/guardian, or physician or other health care provider.
5. Treatment is not a substitute for non-treatment services addressing environmental factors, nor primarily for custodial or respite care.
6. ABA services may be delivered by a Certified Behavior Analyst Assistant (CBAA) or Board-Certified Assistant Behavior Analyst (BCaBA) when operating under the direction and supervision of a Licensed Behavior Analyst (LBA) or Board-Certified Behavior Analyst (BCBA). The LBA or BCBA must provide and document supervision for a minimum of 25% (6.25 hours per week) of the direct therapy hours provided by the CBAA or BCaBA.
   
   
7. A comprehensive medical record is submitted by the ABA provider documenting the course of ABA treatment that includes ALL the following documentation:
   1. Initial assessment request with diagnostic evaluation AND
   2. Individualized treatment plan with measurable goals and objectives that clearly addresses the active symptoms and signs of the member’s core deficits of ASD, formulated based on current assessments with reasonable expectations of mastery within a six-month period. The treatment plan should document these areas:
      1. Communication (e.g. targets related to receptive and expressive communication and social language)
      2. Behavior (e.g. reduction of problem behaviors such as operantly ruminating/vomiting, tantrum behavior, aggression, or self-injurious behavior)
      3. Social (e.g. engaging in social play, engaging in appropriate eye contact, demonstrating setting-specific behaviors)
      4. Academic (e.g. writing letters or lines, shapes identifying sight words, math skills)
      5. Collected data, including additional testing such as ABLLS, VB-MAPP or other developmentally appropriate assessments, celeration charts, graphs, progress notes that link to interventions of specific treatment plan goals/objectives
      6. Documentation supports the total number of goals with the intensity and number of service hours being requested.
      7. Documentation of treatment participants and staff, procedures and setting
      8. Clinical documentation that the ABA therapy is focused on active symptoms of ASD that inhibit daily functioning and that gains made through treatment close the current gap with the member’s functioning level and same age peers
      9. Transition and after-care planning. Transition and aftercare planning should begin during the early phases of treatment. Planning should focus on the development of goals and treatments, as well as the identification of appropriate services and support for the time period following ABA treatment. The transition planning process and documentation should include active involvement and collaboration with a multidisciplinary team. Transition and aftercare goals must be developed specifically for the individual with ASD, be functional in nature, and focus on skills needed in current and future environments. Please refer to the Guidelines for Treatment Record Documentation section of New Directions’ Provider Manual for rules on client file documentation.
      10. Parental participation is recommended for parent training to achieve desired outcomes, which may include but are not limited to reinforcement, task analysis, prompting, fading, shaping and chaining.  When barriers to parent participation are present, the documentation should clearly identify and address those barriers, including how they impact participation and any efforts made to support parent involvement
8. Services provided in a daycare setting are an exclusion of the members’ contract and are excluded.  Services must be delivered in an office setting or through telehealth (CPT codes 97155 97156 are the only services payable as telehealth),
9. Psycho-pharmacotherapy for management of target symptoms or co-morbidities related to ASM may be Medically Necessary
10. Coverage for pharmacotherapy is subject to the member’s specific benefits for drug coverage.  Please check benefit plan description
    ***For groups who do not fall under the Nebraska State Mandate BCBSNE has determined the following procedures and services may be considered not medically necessary as the peer-reviewed medical literature has been determined to be insufficient to find them to be Scientifically Validated in the assessment and treatment of ASD/PDD.
    
     

Medical Policy:  IV.78 Bone Mineral Density Measurement

Effective Date:  11/15/2026
Preauthorization Required: YES

Will utilize InterQual criteria

Note:  this policy does not include CPT 77080