My biggest concern with the proposed ASD diagnostic requirements is what happens to children already receiving ABA therapy who have an established ASD diagnosis from a qualified diagnosing professional using DSM 5 criteria, but without a standardized diagnostic assessment tool. Just because a particular tool wasn't used doesn't mean the diagnosis isn't clinically valid.

I understand what DMAS is trying to accomplish, and I agree that ASD diagnoses need to be properly established. But ASD is a clinical diagnosis based on DSM 5 criteria, and no single standardized assessment tool can independently confirm or rule it out. These tools support the diagnostic process; they don't replace the clinical judgment of a qualified professional.

I think DMAS could accomplish its goal by establishing two pathways for documenting an ASD diagnosis:

Pathway 1: Definitive ASD Diagnosis

DMAS should recognize a comprehensive, face-to-face diagnostic evaluation completed by a qualified LPC, LCSW, LMFT, LCP, physician, NP, PA, or other professional authorized diagnose ASD within their scope of practice and clinical competency.

If the evaluation, including a qualifying Comprehensive Needs Assessment (CNA), documents the DSM 5 criteria, developmental history, and clinical findings supporting an ASD diagnosis, that should be sufficient without automatically requiring standardized testing.

For authorization, ABA providers should be able to submit existing documentation confirming the diagnosis, evaluation date, diagnosing professional's name, credentials and Type 1 NPI, and that DSM 5 criteria were used. The diagnosing professional remains responsible for supporting the diagnosis; ABA providers shouldn't have to independently validate another provider’s diagnostic process.

This pathway should apply regardless of age.

Pathway 2: Provisional ASD Diagnosis

When a qualified diagnosing professional suspects ASD but cannot establish a definitive diagnosis, a provisional ASD diagnosis may be appropriate while further evaluation is pursued.

For children age 5 and younger who meet medical necessity criteria, keep the proposed 6-month follow-up and 12-month EPSDT review, while allowing the diagnosing professional to determine what additional evaluation or testing is necessary.

For children older than 5 without a definitive ASD diagnosis, further evaluation should be pursued, and DMAS should clarify whether ABA services can be considered under EPSDT during that process.

Documentation and Medical Necessity

I think the simplest solution is for DMAS to recognize existing diagnostic documentation, including a CNA when completed by a professional qualified to diagnose ASD and containing sufficient diagnostic findings to support the diagnosis. This would avoid requiring a particular standardized assessment tool or creating another form or signature requirement. DMAS also needs to clarify which professionals are qualified to establish an ASD diagnosis, including appropriately supervised residents and supervisees.

It’s important to remember that having an ASD diagnosis doesn't automatically qualify someone for ABA services. The ABA provider still has to complete its own assessment to establish medical necessity, identify treatment needs, and justify the recommended services and hours. The MCO then reviews that information before authorizing treatment. There are already multiple levels of review built into this process. Requiring a specific diagnostic tool doesn't tell us whether a child actually needs ABA, how many hours are appropriate, or whether treatment should continue. Those decisions should be based on the child's individual needs, functional impairments, and progress in treatment.

Diagnostic verification and utilization management serve different purposes. Requiring a particular standardized diagnostic instrument may provide additional diagnostic information, but it does not establish the medical necessity, intensity, or duration of ABA treatment. If DMAS is concerned about inappropriate utilization, those concerns should be addressed through medical necessity criteria, individualized treatment planning, progress reviews, and authorization oversight rather than diagnostic requirements that could unnecessarily restrict access to treatment for children with otherwise clinically valid ASD diagnoses.

Implementation and Continuity of Care

Most importantly, children already receiving ABA therapy shouldn't have their services interrupted simply because documentation requirements have changed. DMAS should recognize existing clinically supported ASD diagnoses and establish a reasonable transition period when additional evaluation or testing is needed.

DMAS should also clarify that new diagnostic documentation requirements apply prospectively. Previously authorized services should not be subject to retrospective denials or recoupments solely because an established ASD diagnosis was supported by clinical evaluation rather than a standardized diagnostic tool that was not required at the time.

If a subsequent evaluation determines that the child does not meet the diagnostic criteria for ASD or, should ABA no longer be medically necessary, DMAS/MCOs should allow for a shorter, transitional authorization rather than abruptly terminating services. This would give providers time to gradually fade services, focus on maintaining and generalizing acquired skills, coordinate referrals to other appropriate services or levels of care, and complete discharge planning. Abruptly removing an intensive service without a transition plan could disrupt the child's progress and potentially cause harm, particularly when alternative services are not immediately available.

Access to Evaluations

If a referral for screening/testing is needed, the MCOs should help families access qualified providers. DMAS should also establish a clear process for maintaining access to treatment when appointments cannot be completed within the required timeframe due to long waitlists, limited provider availability, geographic barriers, or transportation challenges, particularly for families in rural areas. ABA providers shouldn't be responsible for managing another provider's evaluation process.

If DMAS requires additional diagnostic testing, it needs to clarify which professionals are qualified to administer and interpret those assessments and how the services should be billed and reimbursed. A comprehensive battery of diagnostic testing should be performed by an appropriately qualified professional and billed under the applicable diagnostic or psychological testing codes, not treated as part of an ABA assessment under CPT 97151.