Overview

Aetna (now Aetna/CVS Health) covers Applied Behavior Analysis (ABA) services under Clinical Policy Bulletin #0554. As of 2026, Aetna requires prior authorization for all ABA services, including initial evaluations, direct therapy, and supervision hours. This guide walks through the complete authorization process.

What Requires Prior Authorization

All of the following require prior authorization from Aetna:

  • 97151 — Behavior identification assessment (initial and re-evaluations)
  • 97152 — Behavior identification supporting assessment
  • 97153 — Adaptive behavior treatment by protocol (direct therapy)
  • 97154 — Group adaptive behavior treatment by protocol
  • 97155 — Adaptive behavior treatment with protocol modification
  • 97156 — Family adaptive behavior treatment guidance
  • 97157 — Multiple-family group adaptive behavior treatment guidance
  • 97158 — Group adaptive behavior treatment with protocol modification

    • Required Documentation

    Aetna requires the following documentation for an initial authorization request:

    Diagnostic Documentation

  • DSM-5 or DSM-5-TR autism spectrum disorder diagnosis from a licensed psychologist, developmental pediatrician, or child psychiatrist
  • Diagnostic evaluation dated within 24 months of the authorization request
  • Standardized assessment scores (ADOS-2, ADI-R, or equivalent)

    • Functional Behavior Assessment

  • Comprehensive FBA conducted by a BCBA or BCaBA under BCBA supervision
  • Includes baseline data, target behaviors, and proposed treatment goals
  • Must be dated within 6 months of the authorization request

    • Treatment Plan

    Aetna's treatment plan requirements under CPB 0554 include:

  • Specific, measurable, observable behavioral goals
  • Baseline data for each target behavior
  • Proposed weekly hours by service type (direct therapy, supervision, parent training)
  • Estimated treatment duration
  • Discharge criteria
  • Parent/guardian involvement plan

    • Submission Process

    Step 1: Verify Eligibility and Benefits

    Before submitting, verify:

  • Active Aetna coverage and plan type (HMO, PPO, EPO)
  • ABA benefit inclusion (some employer-sponsored plans exclude ABA)
  • Deductible and out-of-pocket status
  • Any coordination of benefits with secondary insurance

    • Use Aetna's NaviMedix portal or call the behavioral health line at the number on the member's ID card.

    Step 2: Submit via Availity or NaviMedix

    Aetna accepts prior authorization requests through:

  • Availity Essentials (preferred for most providers)
  • NaviMedix (Aetna's proprietary portal)
  • Phone (for urgent requests only)

    • Step 3: Timelines

    Request TypeSubmission DeadlineDecision Timeline
    Initial authorizationBefore first service date15 calendar days (standard)
    Urgent/expeditedBefore or same day as service72 hours
    Concurrent review30 days before current auth expires15 calendar days
    RetrospectiveWithin 30 days of service30 calendar days

    Common Denial Reasons and How to Avoid Them

    1. "Not Medically Necessary"

    Cause: Treatment plan goals are not specific or measurable, or the requested hours are not supported by the assessment data.

    Prevention: Ensure every goal in the treatment plan has a baseline measurement, a target criterion, and a data collection method. The number of requested weekly hours should be explicitly justified by the FBA findings.

    2. "Diagnosis Not Supported"

    Cause: The diagnostic evaluation is outdated (>24 months) or does not include standardized assessment scores.

    Prevention: Track diagnostic evaluation expiration dates. Aetna requires re-evaluation every 24 months.

    3. "Missing Documentation"

    Cause: Incomplete submission — most commonly a missing FBA or a treatment plan that lacks required components.

    Prevention: Use a pre-submission checklist (ABA Insight's Checklist Generator covers all Aetna requirements).

    4. "Provider Not Credentialed"

    Cause: The rendering BCBA or the billing organization is not in Aetna's network, or credentialing is pending.

    Prevention: Verify credentialing status before scheduling the initial evaluation. Credentialing can take 90–120 days.

    Renewal Authorizations

    Aetna typically issues initial authorizations for 6 months. Renewal authorizations require:

  • Updated progress notes showing measurable progress toward treatment goals
  • Updated treatment plan with revised goals if prior goals were mastered
  • Continued medical necessity justification
  • BCBA attestation that ABA remains the appropriate level of care

    • Submit renewal requests at least 30 days before the current authorization expires to avoid a gap in coverage.

    Unit Tracking

    Aetna tracks authorized units on a total authorization basis (not weekly or monthly). This means you have flexibility in how you schedule sessions within the authorization period, as long as you do not exceed the total authorized units.

    Monitor remaining units carefully as you approach the end of the authorization period. Aetna does not automatically notify providers when units are running low.

    Appeals Process

    If Aetna denies an authorization request:

  • Level 1 Appeal: Submit within 180 days of the denial. Include a letter of medical necessity from the treating BCBA and the supervising physician or psychologist.
  • Level 2 Appeal: If Level 1 is denied, request an external review through your state's independent review organization (IRO).
  • Expedited Appeal: Available when the standard timeline would seriously jeopardize the member's health. Decision within 72 hours.

    • Key Contacts

  • Behavioral Health Prior Authorization: Number on member's ID card (look for "Behavioral Health" or "Aetna Behavioral Health")
  • Availity Support: 1-800-282-4548
  • CPB 0554 Reference: Available at aetna.com/cpb/medical/data/500_599/0554.html