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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 1:1 applied behavior analysis (ABA) services (10 hours per week total). Findings:  The physician reviewer found that the presented information, the ABA treatment guidelines set by the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, and the medical necessity definition by Papatola and Lustig, the requested services are not medically necessary. The records do not include any information to support 10 hours of 1:1 ABA therapy per week for treatment of this patients presenting concerns. The CASP and the ABA Coding Coalition have minimum essential elements that must be included with a treatment request to indicate the scope of treatment that is being requested. These elements include comprehensive assessment, direct observable data, individualized and detailed behavior-analytic treatment plan, treatment protocols, and an infrastructure for supervision. Further, the specific elements of the treatment plan must document the reason for referral, background information, assessment procedure and results, treatment plan, transition plan, and discharge plan. As the records provided for review do not include these essential elements or treatment plan components, the requested 10 hours per week of 1:1 ABA services are not medically necessary for this patient. In addition, the requested 10 hours of 1:1 ABA services do not meet several of the medical necessity criteria put forth by Papatola and Lustig. Per the authors, medical necessity criteria for ABA services includes: a) Diagnostic and Statistical Manual V (DSM-V) autism diagnosis supported by symptoms; b) symptoms of diagnosis causing impairment; c) motivation for change exemplified by family involvement; d) interventions are evidence-based and consistent for type, frequency, and duration of treatment; e) goals are constructed with patients family; f) outcomes are measurable; g) occurs in least restrictive environment; h) required for purposes other than convenience of patient or provider; i) measurable reduction in symptoms; j) symptoms are manageable; and k) day-to-day functioning has improved over baseline. Based on the presenting information, the request for 10 hours of 1:1 ABA per week fails to meet the criteria for subsections (b), (c), (e), (f), (g), (h), (i), (j), and (k). The request fails to meet these criteria due to a lack of a treatment plan that meets medical necessity minimum guidelines. Moreover, the requested 10 hours per week of 1:1 ABA therapy services are not in accordance with the generally accepted standards of mental health and substance use disorder care, and are not clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested 1:1 ABA therapy services (10 hours per week total) are not medically necessary for 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 a licensed 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.