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 additional 15 hours of direct 1:1 applied behavior analysis (ABA) therapy (40 hours per week total), additional three hours of supervision per week (seven hours per week total), and two hours of report writing total. Based on the presented information, the treatment guidelines set by the Council of Autism Service Providers (CASP), the ABA Coding Coalition, and the medical necessity definition by Papatola and Lustig, the requested additional 15 hours of 1:1 ABA therapy (40 hours per week total), three hours of supervision (seven hours per week total), and two hours of report writing total is not medically necessary for treatment of this patient. The CASP highlights that focused level of treatment is for 10-25 hours per week and is appropriate for individuals who (a) need treatment only for a limited number of key functional skills or (b) have such acute problem behavior that its treatment should be the priority. The 20 goals detailed in the plan are simple and the patient is making progress on all of them. In addition, the patient is engaging in minimal challenging behavior, thus the currently authorized 25 hours of 1:1 ABA is sufficient to treat the patients presenting concerns. Furthermore, the ABA Coding Coalition indicates that, The dosage of ABA treatment will vary with each patient and should reflect the goals of treatment, patient strengths and needs, patient and caregiver circumstances and preferences, available resources, and the patients response to treatment. The records document that the patient previously made progress meeting 30% of treatment goals and making progress on 54% of remaining goals on previous treatment plan with an intensity of only 20 hours per week 1:1 ABA therapy. As the patient has made progress with a lower intensity of 1:1 ABA, the goals are relatively minimal, and the patient is engaging in low rates of challenging behavior, the current dosage of 25 hours per week of 1:1 ABA and four hours per week of supervision is an appropriate dosage. Moreover, the request fails to meet several medical necessity criteria. The 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. Based on the presented information, the request fails to meet criteria (d) and (h). Although ABA is the most effective evidence based treatment for autism, the requested dosage does not align with established guidelines for intensity. Overall, the requested additional hours of ABA services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Based on these findings, the requested additional 15 hours of direct 1:1 ABA therapy (40 hours per week total), additional three hours of supervision per week (seven hours per week total), and two hours of report writing total is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a 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.