Highmark's Pennsylvania ABA Policy Now Lists Eight Reasons Therapy Can End

Highmark's Pennsylvania commercial medical policy for autism, V-37-045, took effect June 29, 2026. It replaces V-37-044 (effective August 4, 2025) and was last revised in March. The policy applies to Highmark's Pennsylvania commercial business. ABA coverage under it runs through Act 62 of 2008 (fully insured groups of 51 or more employees, and CHIP) or the member's benefit contract. No grace period is stated.

The posted redline marks what is new. Four additions matter to a Pennsylvania practice.

Eight ways therapy can end

The policy now says discontinuation “may be considered” when one or more of these is met:

• medical-necessity criteria are no longer met on current presentation and function;
• therapy at the current intensity is “primarily for convenience rather than clinical benefit”;
• no meaningful progress or improvement across two or more consecutive authorization periods on standardized assessments (it names the Vineland and patient-centered goal measures) “despite appropriate modifications to intervention approach”;
• symptoms, behaviors or impairments develop or worsen due to therapy;
• symptoms have stabilized enough for a less intensive level of care;
• skill acquisition, maintenance and generalization across settings are sustained;
• family, school and community supports can maintain the gains;
• the family cannot participate or adhere to recommendations to the extent needed.

The same revision adds a note that intensity is set by response to treatment, not predetermined hours. The criteria are discretionary and carry no hour caps. They do tell you what a reviewer will look for at reauthorization.

School sessions need a medical goal

The school-setting criteria gain a test: services must address medical treatment goals, such as self-injury, severe aggression or other behavior that impairs health and safety, “rather than solely educational or academic goals” like curriculum access or classroom participation. Services must also not duplicate anything a federal, state or local entity already funds. Services to access a school curriculum under an IEP are listed as not reimbursed.

Documentation and exclusions

Notes must now show the signer's printed name and relationship to the client, and who was present during the session. A new not-medically-necessary list includes ABA billed during speech, OT or PT (carve the time out and note it), therapy that starts before the assessment and treatment plan are complete, respite, custodial care, billing while the member sleeps, provider travel time, transporting or accompanying the member unless it is part of a documented treatment goal, and services rendered by a parent or legal guardian.

Limits

Our source is Highmark's posted redline, not a clean copy, and we could not open a live version to confirm nothing changed after posting. Each line above is taken from text marked as added.

What you must do

• Billing lead: open ten recent Highmark session notes. Check each for the signer's printed name and relationship, and a list of who was present.
• Clinical director: list Highmark clients at two or more authorization periods. If their Vineland or goal data is flat, your reauthorization needs to show what you changed in the intervention.
• School-hours cases: confirm the plan states a health-and-safety goal, not an access goal.
• Anyone scheduling: check for sessions that overlap a client's speech or OT, and for sessions that started before the plan was signed.