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 applied behavioral analysis (ABA) services (1.5-hour sessions, three times a week). The submitted documentation does not support the medical necessity of the requested services. The Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder note the following core characteristics of ABA: (1) an objective assessment and analysis of the clients condition by observing how the environment affects the clients behavior, as evidenced through appropriate data collection; (2) importance given to understanding the context of the behavior and the behaviors value to the individual, the family, and the community; (3) utilization of the principles and procedures of behavior analysis such that the clients health, independence, and quality of life are improved, and (4) consistent, ongoing, objective assessment and data analysis to inform clinical decision-making. The ABA Coding Coalition highlights that service should include the development of a carefully constructed, individualized and detailed treatment plan that utilizes reinforcement and other behavior-analytic procedures and excludes the use of procedures that lack scientific evidence of effectiveness. Papatola and Lustig report that ABA services should be guided by information including the symptoms of diagnosis causing impairment. The authors further note that interventions should be evidence-based and consistent for type, frequency, and duration of treatment, with goals constructed with the patients family, measurable outcomes and reduction in symptoms, occurring in least restrictive environment, required for purposes other than convenience of patient or provider, with day-to-day functioning improving over the baseline. In this case, despite being requested, no treatment plan or assessment results were submitted for review. Without an ABA evaluation and treatment plan highlighting what will be addressed during therapy, it is unclear what will be targeted, and why, during therapy, which autism symptoms are causing impairment and whether the requested intensity is appropriate. In this case, the records do not document goals, measurable outcomes, or location of services. Based on the available records, convenience cannot be ruled out, symptom remediation cannot be measured, symptom management cannot be determined, and without a baseline there is no way to determine if improvement has occurred. Therefore, ABA services (1.5-hour sessions, three times a week) are not medically necessary for the 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.