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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested coverage for 35 hours of direct applied behavioral analysis (ABA) per week. The enrollee was diagnosed with autism spectrum disorder (ASD) and has been receiving applied behavioral analysis (ABA) services with a Board Certified Behavior Analyst (BCBA).Findings: the physician reviewer found that  currently receives 35 hours of ABA services per week. He also receives occupational therapy and speech therapy. His behaviors include vocal stereotypy, non-compliance, elopement, self-injurious behavior, and wrist clapping. Upon re-assessment, there are several behaviors identified as challenging which were targeted with associated goals for improvement, with primary concerns noted at the enrollees elopement, active non-compliance, and self-injury, as well as the repetitive behaviors of vocal stereotypy (severity level two) and wrist clapping (severity level two).  The enrollee has made tremendous progress and met goals by mastering hundreds of exemplars across various domains including those of adaptive curriculum, language curriculum, cognitive curriculum, social curriculum, play curriculum, executive function curriculum. In these domains, additional goals are continually made to continue to forge additional progress for the enrollee. The ABA progress report shows his behaviors have improved in safety awareness, in some language and social skills, and with increased interest in food preparation. Based on review of the records, with the improvement of various core autism symptomology, the ability of the enrollee to engage more fully with other typical peers both socially and academically, and the much decreased risky behaviors, the medical necessity for the current level of 35 hours per week of ABA services is not supported. Historically, the enrollee has had seven years of intensive ABA, and particularly has received more intensive ABA services over the past year, and has followed generally accepted treatment guidelines for gold-standard ABA services and exceeded such guidelines. Per generally accepted practice guidelines, it is recommended that youth enrollees begin receiving intensive services prior to three years/36 months of age in order to obtain the potential long-term benefits of early intensive ABA services.  This enrollee began receiving services regularly since the age of two years of age and without any notation of disruption in such services.  Based on his progress, the hours can now safely be reduced without any substantial anticipated decrease in progress either short or long-term.  Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent psychiatry 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 similar medical condition.