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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for in-home behavioral intervention services including teaching and reinforcing independence with household tasks (cooking, cleaning, laundry). Based on the presented information, the established ABA treatment guidelines by the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, and the medical necessity definition by Papatola and Lustig, the requested in-home behavioral intervention services including teaching and reinforcing independence with household tasks with goals related to cooking, cleaning, and household chores are medically necessary for treatment of this patient. Both the CASP and the ABA Coding Coalition highlight that adaptive skills may be an appropriate part of treatment depending on the patients presentation of skills and deficits. Per the CASP guidelines, Focused ABA treatment may involve increasing socially appropriate behavioror reducing problem behavior. Per the guidelines,  When prioritizing the order in which to address multiple treatment targets, the following should be considered: Behavior that threatens the health or safety of the client or others or that constitutes a barrier to quality of life (for example, severe aggression, self-injury, property destruction, or noncompliance); Absence of developmentally appropriate adaptive, social, or functional skills that are fundamental to maintaining health, social inclusion, and increased independence (for example, toileting, dressing, feeding, and compliance with medical procedures). This patients provider highlighted that the patient engages in higher rates of stereotypy and self-injury while completing self-help tasks. Additionally, the patient requires substantial support in planning, organizing, and executing tasks. This impacts the patients ability to demonstrate emotional self-control, regulation, flexibility, and inhibition. The purpose of these lessons are to provide the patient with skills and safety awareness to increase his coping skills and reduce the occurrence of challenging behaviors that may occur as a result of delays in adaptive areas of functioning. As the focus of these tasks (cooking, cleaning, and household chores) is to decrease the amount of stereotypy and increase self-management, self-monitoring, and independence, the requested services are medically necessary. Further, the request meets the medical necessity criteria outlined by Papatola and Lustig. Their medical necessity definition includes: a) Diagnostic and 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. The providers rationale to support the requested services indicates that these tasks are being targeted to reduce stereotypy, while also simultaneously increase self-management, self-monitoring, and independence. These findings support the requested in-home behavioral intervention services including teaching and reinforcing independence with household tasks as medically necessary. All told, the requested in-home behavioral intervention services including teaching and reinforcing independence with household tasks (cooking, cleaning, laundry) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is 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.