GN 75 ABA GUIDELINE NOTE 75, APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER Line 197 Applied behavioral analysis (ABA), including early intensive behavioral intervention (EIBI), represented by CPT codes 0359T-0374T, is included on Line 197 AUTISM SPECTRUM DISORDERS for the treatment of autism spectrum disorders. ABA services are provided in addition to any rehabilitative services (e.g. physical therapy, occupational therapy, speech therapy) included in Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES that are indicated for other acute qualifying conditions. Individuals ages 1-12 Intensive interventions Specifically, EIBI (for example, UCLA/Lovaas or Early Start Denver Model), is included on this line. For a child initiating EIBI therapy, EIBI is included for up to six months. Ongoing coverage is based on demonstrated progress towards meaningful predefined objectives (objectives should be achieved as a result of the EIBI, over and beyond gains that would be expected to arise from maturation alone) using a standardized, multimodal assessment, no more frequently than every six months. Examples of such assessments include Vineland, IQ tests (Mullen, WPPSI, WISC- R), language measures, behavior checklists (CBCL, ABC), and autistic symptoms measures (SRS). The evidence does not lead to a direct determination of optimal intensity. Studies of EIBI ranged from 15-40 hours per week. Through Oregon’s Senate Bill 365, other payers are mandated to cover a minimum of 25 hours per week of ABA. There is no evidence that increasing intensity of therapy yields improves outcomes. Studies for these interventions had a duration from less than one year up to 3 years. Less intensive ABA-based interventions If EIBI is not indicated, has been completed, or there is not sufficient progress toward multidimensional goals, then less intensive ABA-based interventions (such as parent training, play/interaction based interventions, and joint attention interventions) are included on this line to address core symptoms of autism and/or specific problem areas. Initial coverage is provided for six months. Ongoing coverage is based on demonstrated progress towards meaningful predefined objectives, with demonstration of medical appropriateness and/or emergence of new problem behaviors. Effective interventions from the research literature had lower intensity than EIBI, usually a few hours per week to a maximum of 16 hours per week, divided into daily, twice-daily or weekly sessions, over a period of several months. Parent/caregiver involvement Parent/caregiver involvement and training is recommended as a component of treatment. Individuals ages 13 and older GN 75 ABA Intensive ABA is not included on this line. Targeted ABA-based behavioral interventions to address problem behaviors, are included on this line. The quality of evidence is insufficient to support these interventions in this population. However, due to strong caregiver values and preferences and the potential for avoiding suffering and expense in dealing with unmanageable behaviors, targeted interventions may be reasonable. Behaviors eligible for coverage include those which place the member at risk for harm or create significant daily issues related to care, education, or other important functions. Ongoing coverage is based on demonstrated progress towards meaningful predefined objectives, with demonstration of medical appropriateness and/or emergence of new problem behaviors. Very low quality evidence is available to illustrate needed intensity and duration of intervention. In the single-subject research design literature, frequency and duration of interventions were highly variable, with session duration ranging from 30 seconds to 3 hours, number of sessions ranging from a total of three to 8 times a day, and duration ranging from 1 to 20 weeks. These interventions were often conducted in inpatient or residential settings and studies often included patients with intellectual disabilities, some of which were not diagnosed with autism. Parent/caregiver involvement and training is encouraged. HEALTH EVIDENCE REVIEW COMMISSION (HERC) COVERAGE GUIDANCE: TIMING OF LONG‐ACTING REVERSIBLE CONTRACEPTIVE (LARC) PLACEMENT Approved 11/10/2016 HERC Coverage Guidance Immediate postpartum and postabortion placement of a long‐acting reversible contraceptive (LARC) (implant or intrauterine device) is recommended for coverage (strong recommendation). Note: Definitions for strength of recommendation are provided in Appendix A GRADE Informed Framework Element Description. RATIONALE FOR DEVELOPMENT OF COVERAGE GUIDANCES AND MULTISECTOR INTERVENTION REPORTS Coverage guidances are developed to inform coverage recommendations for public and private health plans in Oregon as they seek to improve patient experience of care, population health and the cost‐ effectiveness of health care. In the era of the Affordable Care Act and health system transformation, reaching these goals may require a focus on population‐based health interventions from a variety of sectors as well as individually focused clinical care. Multisector intervention reports will be developed to address these population‐based health interventions or other types of interventions that happen outside of the typical clinical setting. HERC selects topics for its reports to guide public and private payers based on the following principles: Represents a significant burden of disease or health problem Represents important uncertainty with regard to effectiveness or harms Represents important variation or controversy in implementation or practice Represents high costs or significant economic impact Topic is of high public interest Our reports are based on a review of the relevant research applicable to the intervention(s) in question. For coverage guidances, which focus on clinical interventions and modes of care, evidence is evaluated using an adaptation of the GRADE methodology. For more information on coverage guidance methodology, see Appendix A. Multisector interventions can be effective ways to prevent, treat, or manage disease at a population level. For some conditions, the HERC has reviewed evidence and identified effective interventions, but has not made coverage recommendations, as many of these policies are implemented in settings beyond traditional healthcare delivery systems. 1 Oregon Health Plan Prioritized List changes Timing of Long-Acting Reversible Contraceptive (LARC) Placement The Health Evidence Review Commission approved the following changes to the Prioritized List of Health Services on November 10, 2016, based on the approved coverage guidance, “Timing of Long-Acting Reversible Contraceptive (LARC) Placement.” The changes will take effect on the Prioritized list of Health Services for the Oregon Health Plan on January 1, 2017. 1) Adopt a new Guideline Note as shown below GUIDELINE NOTE 162 LONG-ACTING REVERSIBLE CONTRACEPTIVE (LARC) PLACEMENT Line 6 Long-acting reversible contraceptives (implant or intrauterine device) are included on Line 6 in all settings, including (but not limited to) immediately postpartum and postabortion. The development of this guideline note was informed by a HERC coverage guidance. See http://www.oregon.gov/oha/herc/Pages/blog-long-acting- reversible-contraceptives.aspx. HERC leadership added a letter (http://www.oregon.gov/oha/herc/Documents/LARC-Implementation.pdf) to Medical Directors regarding implementation issues, which references CMS requirements around contraceptive coverage and guidance on ways to implement effective LARC policy. 1 MINUTES HEALTH EVIDENCE REVIEW COMMISSION Clackamas Community College Wilsonville Training Center, Rooms 111-112 Wilsonville, Oregon November 10, 2016 Members Present: Som Saha, MD, MPH, Chair; Wiley Chan, MD; Beth Westbrook, PsyD; Mark Gibson; Leda Garside, RN, MBA; Susan Williams, MD (by phone, left at 2:30); Kim Tippens, ND, MSAOM, MPH; Kevin Olson, MD; Derrick Sorweide, DO; Chris Labhart; Holly Jo Hodges, MD; Gary Allen, DMD; Irene Croswell, RPh. Members Absent: None. Staff Present: Darren Coffman; Ariel Smits, MD, MPH; Cat Livingston, MD, MPH; Denise Taray, RN; Jason Gingerich; Daphne Peck. Also Attending: Jim Rickards, MD; Jesse Little, Kim Wentz, MD, MPH (Oregon Health Authority); Valerie King, MD, MPH, Craig Mosbaek, Rachel Hatchet (OHSU Center for Evidence-based Policy); Margaret Olmon (ABBVIE); Sara Love* (CCO Oregon); Blair Elgren (Osiris); Grant Hamilton (SI-Bone); Duncan Neilson, MD (Legacy); BJ Cavnor* (One in Four); Maria Rodriguez, MD (OHSU, by phone). *provided testimony Call to Order Som Saha, Chair of the Health Evidence Review Commission (HERC), called the meeting to order; role was called. Minutes Approval Meeting materials page 4 MOTION: To approve the minutes of the 10/6/2016 meeting as presented. CARRIES 13-0. Director’s Report Meeting materials page 117 Darren Coffman oriented members to the new beverage service which will help conserve the Commission’s resources. He asked for the Commission’s permission to begin a new multisector interventions topic: Early Childhood Caries Prevention. The Oral Health Advisory Panel, who meet 11/28, are ready and able to take on this topic. Livingston said there likely will be recommendations on services that are outside a dental office, such as in at a primary care office or schools. Members were directed to the scoping statement, found on page 114 of the meeting materials; there were no comments or discussion. HERC Minutes 11/10/16 1 MOTION: To approve a new multisector interventions topic: Early