Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) an additional five hours of direct 1:1 applied behavioral analysis (ABA) therapy (for a total of 25 hours per week) and (2) an additional one hour of BCBA supervision per week (for a total of five hours per week). The Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder highlight that treatment intensity varies and should be based on variables including the complexity and range of treatment goals, and the extent of direct treatment provided, noting that many variables, including the number, complexity, and intensity of behavioral targets and the patients own response to treatment help determine which model is most appropriate. The CASP guidelines further indicate that focused ABA (ten to 25 hours per week) is appropriate for key functional skills that include establishing instruction-following, social communication skills, compliance with medical and dental procedures, sleep hygiene, self-care skills, safety skills, and independent leisure skills. The CASP guidelines note that although the amount of supervision for each case must be responsive to individual client needs, two hours for every ten hours of direct treatment is the general standard of care. The ABA Coding Coalitions model coverage policy indicates that dosage of ABA treatment will vary with each patient and should reflect the goals of treatment, patient strengths and needs, patient and caregiver circumstances and preferences, available resources, and the patients response to treatment. In this case, the patient has responded well to treatment, meeting several of his goals. His treatment plan indicates he will continue to work on goals with an emphasis on self-care, communication,  and hygiene, most of which are not complex, such as making a sandwich, flushing the toilet, unpacking bags, putting away groceries, and cleaning up after a meal. The records note a decrease to near zero in levels of destructive challenging behaviors such as self-injury and aggression. Due to the simplicity of most of the goals in the treatment plan and the limited number and lack of intensity of challenging behaviors (1) an additional five hours of direct 1:1 ABA therapy (for a total of 25 hours per week) are not medically indicated. Papatola and Lustig report that ABA services should be consistent for type, frequency, and duration of treatment, with day-to-day functioning improving over baseline. In this case, day-to-day functioning may not have improved over baseline, as the patients most recent Vineland-3 adaptive composite score is lower when compared to his baseline score. However, the records report that the patient has met goals and is making progress. Given that the patient is already receiving the CASP guideline recommended two hours for every ten hours of direct treatment, (2) an additional one hour of BCBA supervision per week (for a total of five hours per week) is not medically indicated. In this patients case, (1) an additional five hours of direct 1:1 ABA therapy (for a total of 25 hours per week) and (2) an additional one hour of BCBA supervision per week (for a total of five hours per week) are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, (1) an additional five hours of direct 1:1 ABA therapy (for a total of 25 hours per week) and (2) an additional one hour of BCBA supervision per week (for a total of five hours per week) are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.