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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for additional 10 hours per week of applied behavioral analysis (ABA) therapy for a total of 30 hours per week. At issue is whether the requested additional 10 hours per week of ABA therapy (for a total of 30 hours per week) are medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not 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.Based on the presenting information, the requested additional 10 hours per week of ABA therapy for a total of 30 hours per week is medically necessary for treatment of this patient. This decision is based on the Council of Autism Service Providers (CASP) ABA treatment guidelines and the medical necessity definition by Papatola and Lustig. Given the breadth of the goals being addressed, as identified by the patients treatment plan, the request for 30 hours is within existing ABA treatment guidelines. Specifically, CASP outlines the expectations for comprehensive treatment, which includes early intensive behavioral intervention where the overarching goal is to close the gap between the clients level of functioning and that of typically developing peers. These programs tend to range from 30-40 hours of treatment per week. Prior to the pandemic, this patient was closing the gap between his performance and his same-aged peers, as evidenced by his test scores. However, during the pandemic and a subsequent reduction to 20 hours of telehealth therapy, the patients scores decreased, which widened the gap between his skills and his peers. This supports that the reduced hours have been less efficient for the patient. The CASP guidelines highlight that hours are subsequently increased or decreased based on the clients response to treatment and current needs. The patient should receive the recommended dosage of ABA therapy services for 30 hours per week, as this intensity was leading to significant progress. In addition, many of the patients goals include social components to be addressed in small group environments. This suggests that the patient has made substantial progress and focus of treatment has adapted over time. Currently, with the patient focusing on 29 active goals and 6.7 problem behaviors per session, 30 hours is appropriate to address both the skill acquisition and challenging behavior goals. Furthermore, the requested hours also meet the medical necessity criteria outlined 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. The patients treatment plan consists of 29 active goals and targeting challenging behaviors occurring 6.7 times per session. The requested dosage of 30 hours per week of ABA therapy meets the essential health needs of the patient as outlined in the treatment plan. Per the National Autism Center, ABA is the most effective evidence-based treatment for patients with autism. The treatment modality and intensity are consistent with the patients diagnosis and supported by CASP guidelines. The requested services are not for the convenience of the patient or provider. The ABA therapy is planned for the least intensive treatment setting available with in-person services now that vaccinations for COVID-19 are becoming available. Based on the presenting information and current guidelines, the requested additional 10 hours per week of ABA therapy for a total of 30 hours per week are medically necessary for treatment of this patient. Specifically, the requested additional 10 hours per week of ABA therapy for a total of 30 hours per week are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested additional 10 hours per week of ABA therapy for a total of 30 hours per week are not 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.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.