Appeal type: Medical necessity
Decision: Upheld

Autism Spectrum Disorder.
Autism-Related Treatment (including ABA).

Diagnosis: Autism Spectrum Disorder.
Treatment: Applied behavior analysis (ABA) Therapy, Treatment Planning.
The insurer denied Applied behavior analysis (ABA) Therapy, Treatment Planning.
The health plan's determination is upheld. 

The patient is a male who has been diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). He has been receiving Applied Behavioral Analysis (ABA) therapy with the current provider, but he has not received consistent services and has not met goals. The patient has received 7 hours of direct one-to-one (1:1) ABA therapy during his last authorization period.
According to the notes provided, the patient attends high school, where he has a 1:1 aide. He has an Individualized Education Plan in place. He has no dangerous or disruptive behaviors described. He was reported as struggling with executive function and attention, needing redirection and reinforcement. He may choose not to interact with his peers. His Skills Assessment score was 68. An evaluation showed that he exhibited 1 episode per session of walking away, 3 episodes of gross motor stereotypy, 1 episode of sitting outside the group, and 6 episodes of self-talk.
At issue is the medical necessity of Applied behavior analysis (ABA) Therapy, Treatment Planning.

The health plan's determination of medical necessity is upheld in a whole.

The requested health service/treatment of Applied behavior analysis (ABA) Therapy, Treatment Planning is not medically necessary for this patient.
The patient has not been using the ABA hours for which he has been approved. He has received only 7 hours of direct 1:1 ABA therapy during his last authorization period. Lack of consistency in ABA therapy will preclude consistent acquisition of skills, and skill generalization. 
Almost all of the published studies on the dosing of ABA therapy have been conducted in young children. There are conflicting opinions in the medical literature regarding whether the intensity (number of hours per week) of ABA therapy is related to long-term outcomes. Smith et al [1] compared young children with pervasive developmental disorders who were randomly assigned to intensive treatment or parent training. The authors found that the intensive treatment group outperformed the parent training group on measures of intelligence, visual-spatial skills, language, and academics, though not adaptive functioning, or behavior problems.
Reed et al [2] evaluated the effectiveness of home-based early behavioral interventions for children (2:6-4:0 years old) with autistic spectrum disorders was studied over 9-10 months. Measures of autistic severity, intellectual, educational, and adaptive behavioral functioning were taken. The authors found that "high-intensity behavioral approaches (mean 30 hours/week) produced greater gains than low-intensity programs (mean 12 hours (h)/week)," but also noted that "within the high-intensity groups, increased temporal input on the program was not associated with increased gains in the children."
Linstead et al [3] investigated the relationship between treatment intensity and treatment outcomes. The authors followed 726 children, ages 1.5 to 12 years old, receiving community-based behavioral intervention services. They found that results indicated a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In contrast, Orenstein et al [4] reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes; the age at which ABA therapy was started and duration of treatment was correlated with outcome. Luiselli et al [5] reached similar conclusions.
Therefore, applied behavior analysis (ABA) Therapy, Treatment Planning are not medically necessary.