Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autistic Disorder. 
Treatment: Applied Behavioral Analysis (ABA) for Current Procedural Terminology Code (97153): Adaptive behavior treatment by protocol, administered by technician, (13 hours per week), and CPT Code 97155: Adaptive behavior treatment with protocol modification, administered by a qualified healthcare professional, (one hour per week). 
The health plan denied Applied Behavioral Analysis (ABA) for Current Procedural Terminology Code (97153): Adaptive behavior treatment by protocol, administered by technician, (13 hours per week), and CPT Code 97155: Adaptive behavior treatment with protocol modification, administered by a qualified healthcare professional, (one hour per week). 
The health plan's determination is upheld. 

The patient is a female who was diagnosed with autism spectrum disorder (ASD). The diagnostic evaluation included direct observation, a parent interview, use of the Vineland Adaptive Behavior Scales Third Edition (Vineland-3) and administration of the Mullen Scales of Learning and the Autism Diagnostic Observation Scale, Second Edition (ADOS-2). 
Before diagnosis, the patient's parents noted that she was not using as many words as her peers. Her eye contact was poor and she exhibited repetitive behaviors including hand posturing, flipping parts of toys, and scrutinizing toys when held close to her face. She developed tantrums, screaming and throwing herself to the floor. The Yale Child Study team noted poor eye contact, decreased oral language, and emerging play skills. On the Mullen Scales her receptive language was estimated at 11 months' and expressive language at 16 months' age equivalence. 
In a subsequent evaluation, the patient met 14.5 of 170 milestones on the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP). Using the Early Start Denver Model Curriculum Checklist, she met criteria on 20 out of 321 skill milestones, 6 percent (%) of those typically seen in a child her age. 
She is described as having significant deficits in social-emotional reciprocity, verbal and non-verbal communication, decreased awareness of her environment, and limited early play skills. She can be non-compliant. Her maladaptive behavior has been assessed as being mild and her social communication and self care deficits are assessed as being severe. 

The Applied Behavioral Analysis (ABA) Services: Adaptive Behavior Treatment by Protocol, Administered by Technician (13 Hours per Week), and Adaptive Behavior Treatment with Protocol Modification, Administered by a Qualified Healthcare Professional (One Hour per Week) is not medically necessary for this patient. 

The patient has been approved for some ABA services including ABT (27 hours per week), ABT with modification (5 hours per week) and family ABT guidance (1 hour per week). This is appropriate. She also receives occupational, physical and speech therapy, requiring additional time each week. Additionally, there are conflicting opinions in the medical literature regarding whether the intensity (number of hours per week) of ABA therapy is related to long-term outcome. 

Reed et al [3] evaluated "the effectiveness of home-based early behavioral interventions for children with autistic spectrum disorders". The authors found that "high-intensity behavioral approaches (mean 30 hours per week) produced greater gains than low-intensity programs (mean 12 hours per week)", but also noted that "within the high-intensity groups, increased temporal input on the program was not associated with increased gains in the children." 
Linstead et al [4] investigated the relationship between treatment intensity and treatment outcomes. They found that results indicated a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In contrast, Orinstein et al [5] reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes; the age at which ABA therapy was started and duration of treatment was correlated with outcome. Luiselli et al [6] reached similar conclusions.