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 25 hours of direct applied behavioral analysis (ABA) therapy per week. The records provided for review document that this patients provider has recommended 10 hours of ABA therapy per week over the last several years, but this request was increased to 20 hours per week during the June 2020 and December 2020 treatment plans. The provider indicated that the increase in hours is to address behavior concerns and provide greater access to treatment. However, the patient has historically made progress with 10 hours of ABA therapy per week and he is currently displaying near zero levels of problem behaviors, which include protesting and climbing. The Council for Autism Service Providers (CASP) guidelines highlight that the intensity of treatment reflects the breadth of treatment goals, challenging behavior, and rate of progress. As this patient is making progress, displays minimal challenging behaviors, and is working on 11 active goals, 10 hours per week is appropriate to address the areas identified in the treatment plan. According to Papatola and Lustig, medically necessary ABA services 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. Based on these criteria, the patients request does not meet criteria (c) and (d). Specifically, the CASP guidelines highlight that lower levels of focused treatment are appropriate for the scope of treatment being requested by the provider. As these goals can be addressed with the authorized 10 hours of ABA per week, the request for 25 hours is not consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. Further, a history of the patients care highlights that the patient has historically received 10 hours of ABA per week. It was only during the pandemic where there was a significant increase in hours requested, yet there were no significant changes to the goals or scope of treatment. Specifically, in December 2019, the provider requested 10 hours of ABA per week while working on 15 active goals, while in December 2020 the request is for 20 hours of ABA per week while only addressing 11 active goals. As the provider is requesting more hours but is working on fewer skills especially with a lack of challenging behavior the increase in hours could be out of convenience of the provider or comfort of the patient. Based on these findings, the requested 25 hours per week of direct ABA therapy 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.