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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for seven hours per week of applied behavior analysis (ABA) therapy (for a total of 40 hours per week, across all settings). The Council of Autism Service Providers (CASP) notes that, Treatment dosage, which is often referenced in the treatment literature as intensity will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. The ABA Coding Coalition and CASP suggest that a comprehensive program includes 30-40 hours per week of direct services with additional hours for supervision and caregiver training. Linstead and colleagues found that ABA treatment intensity had significant effects on all eight domains of development for children with autism, with greater intensity having positive impacts across all areas of development. With respect to medical necessity, Papatola and Lustig indicate that to meet the requirement of medical necessity ABA services must be  (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. Per the assessment conducted by the provider and documentation provided by the patients preschool, the patient demonstrates emerging skills in the classroom environment. However due to the patients symptoms of autism, he requires 1:1 support to meet treatment objectives in the preschool setting. Per the records, the patients autism symptoms suggest that intervention in a naturalistic social setting such as preschool appropriate include deficits in communication, play and leisure, social interaction, daily living skills, and community safety. Based upon the clinical assessment completed by the patients provider, many goals are appropriate for implementation in the preschool environment and in fact will most efficiently and appropriately be implemented in a naturalistic social environment including goals targeting social play with peers. On review of the records and medical literature, the intensity requested 40 hours direct ABA services per week are appropriate to meet the essential health needs of the patient as outlined in the treatment authorization request. ABA treatment is consistent with the diagnosis of autism. The requested intensity of ABA services is within established guidelines for intensity and the increase in hours to 40 per week will allow the treatment team to provide services in a least restrictive treatment environment consistent with guidelines. Furthermore, the 40 hours per week of ABA services are medically necessary for prevent progression of the patients health conditions. Given these findings, the additional seven hours per week (40 hours per week total) of direct ABA services 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 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.