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 10 additional supervision hours over a six-month period (for a total of 100 supervision hours over a six-month period), one additional hour per week direct applied behavior analysis (ABA) services (for a total of 16 hours per week direct ABA services), and/or potty training to be included in the ABA therapy. The Council of Autism Service Providers (CASP) and ABA Coding Coalition guidelines provide insight into the level of support for treatment of this patients autism and associated delays. The CASP highlights that for ABA to be medically necessary, A developmentally appropriate ABA assessment process must identify strengths and weaknesses across domains and potential barriers to progress. The information from this process is the basis for developing the individualized ABA treatment plan. Further, the CASP noted that, Each goal should be defined in a specific, measurable way to allow frequent evaluation of progress toward a specific mastery criterion. The requested additional supervision hours and the addition of toilet training have not been specifically evaluated and there is a lack of data regarding the patients baseline level of skill in terms of toileting. Further, the requested additional supervision hours are not consistent with current guidelines. The provider indicated the patient could make progress with the proposed goals with the specified amount of therapy consisting of 15 hours per week and supervision with 90 hours over six months. The ABA Coding Coalition indicates that, Although the amount of case supervision and direction of technicians by the behavior analyst must be responsive to individual patient needs, two hours for every 10 hours of direct treatment is the general standard of care. This patient is currently receiving approximately just over three hours of supervision per week, which is just over the 20% outlined by the ABA Coding Coalition. An additional 10 hours of supervision over six months would provide the patient with supervision hours beyond the 20% outlined by the ABA Coding Coalition. Furthermore, the requested additional 10 hours of supervision and the addition of toilet training to the patients existing ABA treatment plan do not meet the medical necessity criteria outlined by researchers. Per the authors, a medical necessity definition includes a) Diagnostic Statistical Manual 5 (DSM-5) autism diagnosis supported by symptoms, b) symptoms of diagnosis causing impairment, c) motivation for change exemplified by family involvement, d) interventions are evidence-based and consistent for type, frequency, and duration of treatment, e) goals are constructed with patients family, f) outcomes are measurable, g) occurs in least restrictive environment, h) required for purposes other than convenience of patient or provider, i) measurable reduction in symptoms, j) symptoms are manageable, and k) day-to-day functioning has improved over baseline. Specifically, the requested additional supervision hours and one hour per week of ABA therapy do not meet criterion (d), as they are beyond what is being clinically recommended by the provider. The requested toileting to be added to existing ABA therapy does not meet criteria (d) or (k). Toileting was not assessed or requested as part of the most recent request and the records do not document the patients baseline data. Moreover, the requested 10 additional supervision hours over a six-month period (for a total of 100 supervision hours over a six-month period), one additional hour per week direct ABA services (for a total of 16 hours per week direct ABA services), and/or potty training to be included in the ABA therapy are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral condition. Therefore, the requested 10 additional supervision hours over a six-month period (for a total of 100 supervision hours over a six-month period), one additional hour per week direct ABA services (for a total of 16 hours per week direct ABA services), and potty training to be included in the ABA therapy are not medically necessary for treatment of this patient.