Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder. 
Treatment: Autism Related Treatment  (including ABA). 
The insurer denied increase of 14 hours per week of ABA direct therapy. 
The denial is upheld in whole.

The patient is a male who has been diagnosed with an autism spectrum disorder. Records reviewed included letters and reports by his Applied Behavioral Analysis (ABA) provider, health plan letters, and the patient's school Individualized Education Plan.
The patient has been receiving ABA therapy for years. He had been receiving 38 hours of direct ABA therapy per week. Due to the coronavirus pandemic, his school was closed. An increase in maladaptive behavior was described by his ABA therapist. Behaviors included self-harm, property destruction, elopement, difficulty communicating with others, and difficulty identifying and managing negative feelings. The ABA provider increased his direct ABA hours to 52 per week and is requesting an increase of 14 hours per week of direct ABA therapy. The provider describes a decrease in maladaptive behaviors with an increase in hours.
Documentation indicates that the patient has been making progress with his goals of therapy. Some of the goals, such as completing homework and household chores, do not appear to be directly medically necessary goals.
The Individualized Education Plan describes that on the Developmental Profile completed, he scored less than < 0.1 percentile for both cognitive and social/ domains emotional. He was described as being functionally non-verbal. On the Peabody Picture Vocabulary Test 4th Edition, he scored < 0.1 percentile. His receptive language skills were reported to be stronger than his expressive language.
At issue in this review is whether the requested Increase of 14 Hours per Week of Applied Behavioral Analysis (ABA) Direct Therapy is medically necessary.

The health plan's determination is upheld in whole.

The requested health service/treatment of Requested Increase of 14 hours per week of Applied Behavioral Analysis (ABA) Direct Therapy is not medically necessary for this patient. The patient has been approved for 38 hours of direct ABA therapy and has been as making progress with this amount. While an increase in maladaptive behavior was reported at the start of the coronavirus lockdown, his behaviors have decreased in frequency, and the on-going need for the increase of 14 hours per week of direct ABA therapy does not appear to be supported. Some of the goals addressed by his direct ABA hours (such as homework completion) appear more educational than medical.
Orinstein et al. [1] 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 documented therapy was started, and the duration of treatment was correlated with outcome. Luiselli et al. [2] reached similar conclusions.
Tiura et al. [3] performed a study involving 35 children with an autism spectrum disorder, average age 3 years, to determine predictors of benefit from ABA therapy. Using a growth curve analysis, they investigated if age, diagnosis severity, cognitive functioning, treatment hours, gender, parent education level, or primary language is spoken at home significantly predicted the growth trajectories of ABA treatment outcomes. Using the Developmental Profiles-3rd Edition, they found that indicated that higher cognitive functioning significantly predicted faster growth across all four developmental domains, age at entry predicted initial status and other variables only predicted growth rates in one or two domains.