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

The patient has requested 35 hours per week of one-to-one applied behavioral analysis (ABA) intervention for six months. To determine the medical necessity of ABA provides guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and 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. Using this definition, ABA services are supported as medically necessary for this patient. ABA therapy has been identified as the most evidence based treatment for patients with autism by the National Autism Center. Further, the Behavior Analyst Certification Board (BACB) practice guidelines for ABA therapy state that ABA treatment should be delivered in settings that maximize treatment outcomes for the individual patient. In this case, the patient would benefit from comprehensive one-to-one ABA services delivered in the clinic setting, with the goal to generalize gains to other settings as targets are acquired. Recent research supports the implementation of clinic-based ABA over in-home services, noting patients who received both home and center-based services mastered 100% more exemplars per hour while at the center compared to home. Based on the data provided, 35 hours per week of one-to-one ABA therapy for six months is medically necessary to treat this patients autism. Although underutilization of hours is an obstacle towards optimal progress, it does not change the requirements of the patients medical disorder. The patient has demonstrated a high level of need with intellectual disability and language impairment as well as deficits across several core domains, including social communication skills, restricted and repetitive behaviors, and maladaptive behaviors. The data presented also supports the need for higher intensity services at 35 hours per week, based on more cumulative targets acquired at this dosage and the presence of maladaptive behaviors that require immediate intervention and support. All told, the records demonstrate that the requested 35 hours per week of one-to-one ABA intervention for six months is medically necessary for treatment of this patients medical condition. 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 psychologist and a board certified behavior analyst 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.