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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the 40 hours per week of direct applied behavior analysis (ABA) therapy, eight (8) hours per week of supervision, and three (3) hours per week of caregiver training provided, and prospective authorization and coverage for 40 hours per week of direct ABA therapy, eight (8) hours per week of supervision, and three (3) hours per week of caregiver training. To determine the medical necessity of ABA, research provides guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and 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 patients family is requesting continued coverage of comprehensive ABA to address maladaptive behavior including behaviors that are placing the patient, and others, at risk for harm, sensory stimulatory behaviors, and several interfering behaviors. Further, the providers treatment plan highlighted self-care, social skills, and generalization as focal points for the patients treatment. The purpose of treatment for this patient is to increase independence and decrease maladaptive behavior and is not for comfort or convenience. According to the providers letter, since the reduction of treatment intensity, many of the patients problem behaviors have intensified. Specifically, aggression and spitting rose to 90 times higher than the baseline rate. These behaviors decreased, but this is still significantly higher than rates observed when treatment was more intensive. Given these findings, 40 hours per week of direct ABA therapy, eight (8) hours per week of supervision, and three (3) hours per week of caregiver training provided, and future services including 40 hours per week of direct ABA therapy, eight (8) hours per week of supervision, and three (3) hours per week of caregiver training are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychology and is a board certified behavioral analyst 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.