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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) for summer break and nine hours per month of supervision. 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. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism and is required to meet the essential health needs of the patient. To address the issue of dosage, Council for Autism Service Providers (CASP) recently released updated practice guidelines for healthcare funders, which indicate that recommendations for treatment intensity should be made by a BCBA, as these providers have expertise and formal training specifically in ABA for the treatment of autism. Thus, although the neuropsychological evaluation yielded useful information about the patients skills across several cognitive, academic, and problem-solving abilities, an ABA provider is more qualified to provide specific recommendations for ABA therapy dosage. Medically necessary treatment remains the same regardless of time of year, as treatment should not be based on convenience. Finally, the CASP guidelines advocate for the inclusion of treatment goals that target the absence of developmentally appropriate adaptive, social, or functional skills that are fundamental to maintaining health, social inclusion and increased independence. A treatment plan from the ABA provider dated 1/10/20 noted 25 hours per week of direct ABA therapy was recommended. A more recent treatment plan from the ABA provider dated 7/17/20 noted 21 hours per week of direct ABA therapy was recommended. The providers updated recommendation of 21 hours ABA is medically appropriate. Additionally, the requested nine hours per month of supervision is medically necessary to target the goals outlined in order to treat the patients autism. Given these findings, 21 hours of ABA services per week for summer break and nine hours per month of supervision are medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is 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.