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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for applied behavior analysis (ABA).At issue is in this case is whether the requested ABA is medically necessary for treatment of the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A). California Health and Safety Code section 1374.72(a)(3)(A) states that 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.; and (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.Council of Autism Service Providers (CASP) outlines several variables when determining the intensity of ABA therapy. Per CASP, Treatment may vary in terms of intensity and duration, the complexity and range of treatment goals, and the extent of direct treatment provided. Many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. Additionally, Papatola and Lustig outlined criteria for clinicians using ABA to treat autism. The criteria includes health-care 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.In this case, the requested service includes 22 goals that are all within the established treatment guidelines listed above. While four of the goals under the adaptive/self-help section are related to money management, the goals are related to adjusting social behavior to suit various contexts, which is one of the diagnostic criteria of autism Specifically, the goals ensure that patients are displaying appropriate behavior in social contexts and making social decisions based on the information available to them. Therefore, the requested ABA is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.