Exclusion

POLICY:

General Non-Covered Criteria

Services related to this policy are not covered when any of the following apply:

• The service does not meet the medical necessity criteria listed in section 5.1.
• The recipient does not meet the eligibility requirements listed in section 5.
• The service unnecessarily duplicates another provider's service or level of care.
• The service is not authorized when prior authorization is required by the applicable payer.

Specific Non-Covered Criteria

The following are not considered covered behavior analysis services under this agency:

• Any procedure or physical crisis management technique involving seclusion or the use of manual, mechanical, or chemical restraint to control behavior, unless otherwise permitted under applicable law and payer requirements. The agency's prevention-based position and the narrow, emergency-only conditions for any physical intervention are set out in the Restraint, Seclusion, and Restrictive Procedures policy.
• Services provided solely for recipient supervision, personal care assistance (e.g., functioning as a 1:1 aide), companionship, chaperoning, or shadowing, regardless of activity or setting. This includes supports that:
  • Are reimbursable under a different benefit category or service line; or
  • Can be provided by individuals without professional training, licensure, or certification in behavior analysis.
• Caregiver or childcare services.
• Psychological testing, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, or long-term counseling.
• Services funded under section 110 of the Rehabilitation Act of 1973.
• Services not included on the applicable payer's fee schedule or not authorized under the payer contract.
• Services provided simultaneously by more than one behavior analysis provider, unless determined to be medically necessary, prior authorized, and indicated in the approved behavior plan.
• Travel time, unless explicitly covered and authorized by the applicable payer.