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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 15 hours of in-home applied behavioral analysis (ABA) services.Findings:  The physician reviewer found that presenting information, the ABA treatment guidelines set by the ABA Coding Coalition and the Council of Autism Service Providers (CASP), and the medical necessity definition by Papatola and Lustig, the requested 15 hours of in-home ABA services are not medically necessary for treatment of this patient. Both the ABA Coding Coalition and CASP highlight that A developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. The information from this process is the basis for developing the individualized ABA treatment plan. While a partial assessment was completed in February 2021, ABA was not recommended at that time. As such, a new ABA assessment must be completed to ascertain the patients current level of strengths and weaknesses, identifying the deficit areas that will be addressed during treatment. In the absence of an assessment and individualized treatment plan identifying specific goals, the intensity required to address those goals cannot be identified. While the patients family submitted information from school-based assessments, these documents are for educational purposes and a medical ABA evaluation needs to be conducted to support a medical need for ABA services. In addition, the requested 15 hours of in-home ABA therapy per week does not meet the medical necessity definition by Papatola and Lustig. According to Papatola and Lustig, 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. Since there is no ABA assessment or treatment plan accompanying the request, the patient fails to meet criteria (a) through (e). Specifically, without an updated assessment and treatment plan it is unclear whether 15 hours of in-home ABA therapy services per week will meet the essential health needs of the patient. Similarly, without this information we cannot determine if the requested hours are consistent in type, frequency, and duration with existing medical guidelines. Based on the presenting information, the requested 15 hours of in-home ABA services 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.