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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for two months of eight hours per week of applied behavior analysis (ABA) therapy, two hours per week of supervision, and two hours per week of parent training and reimbursement and prospective authorization and coverage for six months of 10 hours per week of ABA therapy, two hours per week of supervision, and two hours per week of parent training for treatment of the enrollees severe emotional disturbance of childhood.Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue.  ABA therapy is a medically necessary intervention for the treatment of severe behavioral disorders, and this treatment remains one of the most evidence-based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address aggression, elopement, property destruction and tantrums.  A treatment plan has been developed that is consistent with the patients essential health needs. The correlation between treatment outcomes and treatment intensity is well-documented.  In the article on the efficacy of ABA therapy by Linstead and colleagues, the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this article, 726 children were studied and were shown to make increased progress towards learning objectives with increased intensity of treatment.  Up to this point, the patient appears to have made progress in many areas as discussed above, but he continues to demonstrate significant behavioral concerns in lieu of the multiple transitions he is experiencing. The patient continues to require a high level of support to transition appropriately. Per the records, he requires ABA therapy to address the reemergence of behaviors. Failure to master these skills not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. The current medical evidence supports the services at issue in this clinical setting. All told, eight hours per week of applied behavior analysis (ABA) therapy, two hours per week of supervision, and two hours per week of parent training and 10 hours per week of ABA therapy, two hours per week of supervision, and two hours per week of parent training were and are medically necessary for the treatment of this patient. The submitted documentation supports the medical necessity of the services at issue.  ABA therapy is a medically necessary intervention for the treatment of severe behavioral disorders, and this treatment remains one of the most evidence-based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address aggression, elopement, property destruction and tantrums.  A treatment plan has been developed that is consistent with the patients essential health needs. The correlation between treatment outcomes and treatment intensity is well-documented.  In the article on the efficacy of ABA therapy by Linstead and colleagues, the authors noted a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this article, 726 children were studied and were shown to make increased progress towards learning objectives with increased intensity of treatment.  Up to this point, the patient appears to have made progress in many areas as discussed above, but he continues to demonstrate significant behavioral concerns in lieu of the multiple transitions he is experiencing. The patient continues to require a high level of support to transition appropriately. Per the records, he requires ABA therapy to address the reemergence of behaviors. Failure to master these skills not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. The current medical evidence supports the services at issue in this clinical setting. All told, eight hours per week of applied behavior analysis (ABA) therapy, two hours per week of supervision, and two hours per week of parent training from 6/06/17 through 8/20/17 and 10 hours per week of ABA therapy, two hours per week of supervision, and two hours per week of parent training from 8/21/17 through 2/21/18 were and are medically necessary for the treatment of this patient. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification developmental-behavioral pediatrics 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.