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

Nature of Statutory Criteria/Case Summary: The parent of a 17-year-old male enrollee has requested authorization and coverage for 38 hours per month of direct 1:1 applied behavior analysis (ABA) services (CPT code H2019)for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that a review of the record indicates that the enrollee has been diagnosed with autism spectrum disorder. In a report dated 9/5/18, the enrollees provider noted that the enrollee was able to problem-solve placing/arranging items without prompts or models from others. The enrollee was noted to require prompts for sustained attention across multiple tasks and required prompting to respond to questions asked. The enrollee was noted to miss directives from various adults. In a letter dated 11/1/18 the provider noted the enrollee exhibited significant maladaptive behaviors, including self-injurious behavior, loud verbal outbursts and physical aggression towards others. The provider noted 38 hours per week of the ABA treatment program met the enrollees needs; and that a reduction to 25 ABA hours per week caused severe regression and an increase in maladaptive behaviors. The enrollees provider has recommended 38 hours per month of direct 1:1 ABA services for the enrollee.At issue in this case is whether the requested services, 38 hours per month of direct 1:1 applied behavior analysis (ABA), are medically necessary for treatment of the enrollees behavioral health condition. While the individual has made many developmental gains, their Vineland scores are significantly discrepant from their same aged peers. Further, this highlights that while the patient may display skill acquisition in one setting, they have been unable to generalize these gains to novel environments. Further, the patient continues to engage in maladaptive behaviors (e.g., stereotypy, self-injury) several times an hour, which will inhibit their ability to independently navigate their environment. While many of the patient's goals are continuations of the previous authorization, two goals were met, many were almost met, and five new goals were added. While one would expect more goal acquisition, goals at the executive functioning level are often more complex than teaching basic language skills. Further, the presence of maladaptive behavior can extend the duration of skill acquisition. The National Standards Project (National Autism Center, 2015) identifies that applied behavior analysis (ABA) is the most effective treatment for autism; but also indicates that ABA is also the most effective treatment for adults with autism. While the patient is not an adult, he is older than many participants that many research studies reference. Further, in response to high recommended hours, the Behavior Analyst Certification Board (BACB, 2014) indicates that `Although the recommended number of hours of therapy may seem high, this is based on research findings regarding the intensity required to produce good outcomes. It should also be noted that time spent away from therapy may result in the individual falling further behind typical developmental trajectories. Such delays will likely result in increased costs and greater dependence on more intensive services across their life span.` This is important, as the patient is accessing a higher level of services now, to avoid requiring the same level of service, or more, as an adult. Therefore, based on the presenting information and the presented research, the services are medically necessary.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 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.