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

Nature of Statutory Criteria/Case Summary: The parents of the enrollee have requested reimbursement and prospective authorization and coverage for an additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 11/12/20 through 5/12/21.At issue in this case is whether the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 11/12/20 through 12/31/20 were medically necessary to treat the patients condition. Were and/or are the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 1/01/21 through 5/12/21  medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A)? California Health and Safety Code section 1374.72(a)(3)(A) states that Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration.; and (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Council of Autism Service Providers (CASP) outlines several variables when determining the intensity of ABA therapy. Per CASP, Treatment may vary in terms of intensity and duration, the complexity and range of treatment goals, and the extent of direct treatment provided. Many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. Additionally, Papatola and Lustig outlined criteria for clinicians using ABA to treat autism. The criteria includes health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. In this case, the patients ABAS III  scores were within one standard deviation of the mean, or in the low average range. The provider has outlined 20 goals, many of which are communicative and social in nature. As the goals themselves are not complex, the challenging behavior is minimal and not a threat to the patient or others, and the patients adaptive functioning was identified to be in the low average range, 25 hours per week of 1:1 ABA therapy is sufficient to meet the patients essential health needs. Moreover, the requested additional 15 hours of 1:1 ABA therapy fails to meet the criteria outlined by Papatola and Lustig. As stated above, 25 hours per week 1:1 ABA therapy is sufficient to meet the patients medical needs, given the ability level of the patient, the complexity of the goals being requested, and a lack of challenging behavior. The requested 40 hours total of 1:1 ABA therapy per week would be beyond what is necessary according to CASP guidelines. Therefore, an additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 11/12/20 through 12/31/21 were not medically necessary for the treatment of the patients medical condition. Additionally, the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, from 1/01/21 through 5/12/21 were not and are not medically necessary as defined in Health and Safety code section 1374(a)(3)(A). Specifically, the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, provided from 1/01/21 through 5/12/21 were not and are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC provided 1/01/21 through 5/12/21 were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The additional 15 hours per week of ABA, for a total of 40 hours per week provided by California Unified Service Providers, LLC, were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the services at issue are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.