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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for five hours a week of one-to-one (1:1) applied behavioral analysis (ABA) therapy services. Based on the Council of Autism Service Providers (CASP) guidelines on ABA treatment for patients with autism and the medical necessity definition by Papatola and Lustig, the requested five hours a week of one-to-one ABA therapy services are medically necessary for treatment of this patient. Although the patient did not meet all of the goals outlined in the most recent treatment plan, she did make progress on all goals included in the plan. The CASP guidelines indicate that a patient can be discharged from treatment if they fail to make progress for successive authorization periods. However, this patient has made some progress toward goals, and she remains more than one standard deviation from the mean on all areas on the Vineland-3, and two standard deviations for socialization, indicating that much progress can still be made. The provider has recommended a discharge date of December 2021. While the patient has received ABA for several years, it is evident that there has been a reduction in intensity over successive authorizations. In addition, the providers recommendation for five hours per week of ABA services is consistent with the requirements for medical necessity outlined by Papatola and Lustig. Per the authors, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. The provider outlined the goals to be addressed during the highly focused level of intervention being requested, which meets the essential health needs of the patient. Per the Council of Autism Service Providers (CASP), ABA is the most effective evidence based treatment for autism. Thus, ABA is consistent with the patients diagnosis. ABA for five hours per week is appropriate in type, frequency, and duration to address this patients remaining goals. The request of such a low level of treatment does not appear to be for convenience of the patient or provider, and the home setting is the least restrictive treatment environment. The patient is working toward generalization and discharge. Given these findings, the requested five hours a week of one-to-one ABA therapy services are medically necessary for treatment of this patient as defined by California Health and Safety Code section 1374(a)(3)(A). Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.