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

 The parent of an enrollee has requested authorization and coverage for Intensive Outpatient Program services (cognitive behavioral therapy, behavioral interventions, occupational therapy, speech therapy, small group social skills therapy, and intensive parent training) 3 hours per day, 5 days per week, for 60 days, or for 30 days.Papatola and Lustig explain that a typical medical necessity evaluation for behavioral interventions will consider whether 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.In this case, the submitted documentation reflects that it has not been determined whether or not the patient qualifies for a diagnosis of Autism Spectrum Disorder in addition to the other diagnoses listed. While the information presented for review repeatedly references severe and debilitating anxiety, the submitted documentation does not include a psychological evaluation by a licensed clinical psychologist that results in a diagnosis of clinical anxiety. In addition, while anecdotal information presented by the patients caregivers as well as a letter from the patients pediatrician indicate that the patient is a danger to himself and others, the submitted records do not document a history of self-harm or aggression towards others. Specifically, observations presented as part of the psycho-educational evaluation completed by the school on multiple occasions did not note that any severe aggressive or self-injurious behaviors were observed. Furthermore, during the comprehensive psycho-educational evaluation, no severe or dangerous behaviors that precluded the patient from taking part in the evaluation were described. Based on the clinical information that has been provided, the patient appears to have many symptoms that are common in those with autism spectrum disorders, primarily difficulties with social communication, social interactions, interfering behaviors, difficulties with change and inflexible adherence to routines, and sensory sensitivities. The physician reviewer found that these symptoms are most consistent with a diagnosis of Autism Spectrum Disorder, for which Applied Behavior Analysis therapy would be the most appropriate treatment. Accordingly, the submitted records suggest that the essential health needs of the patient are unclear, that the patients diagnoses are still in question, and that there is not sufficient evidence that a less intensive setting would be inappropriate for the patient. Under these circumstances, Intensive Outpatient Program services 3 hours per day, 5 days per week, whether for 60 days or for 30 days, is not medically necessary to treat the patients medical condition.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.