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 an additional nine hours per week of direct care applied behavior analysis (ABA) services (20 hours per week total), 1.5 hours per week of speech therapy services (2.5 hours per week total), and two hours per week of occupational therapy services (three hours total per week). Based on the presenting information, the requested additional nine hours of 1:1 ABA therapy per week (20 hours total) are not medically necessary for treatment of this patient. This decision is based on treatment guidelines set by the ABA Coding Coalition and the medical necessity criteria set by researchers. Both the ABA Coding Coalitions model policy and the Council of Autism Service Providers (CASP) guidelines for autism highlight the requirements to support ABA services. Applying these guidelines there is a lack of clinical rationale to support an increase in ABA services from 11 hours per week to 20 hours per week. The patients provider evaluated his ability level through standardized assessments in addition to interviewing caregivers. The provider determined that the treatment intensity should be 11 hours per week. There has been an overall lack of progress in the previous authorization periods. The patients challenging behaviors are minimal, and the scope of the goals can be addressed with 11 hours of ABA per week. Additionally, the caregiver request to increase individual ABA by nine hours per week (20 hours total per week) does not meet the medical necessity criteria outlined by medical literature. According to researchers, 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. In this patients case, the request to increase ABA by nine hours per week fails to meet criteria (a), (c), and (d). Specifically, without supporting documentation via a thorough assessment justifying the increase, the requested additional nine hours of ABA services are not supported as necessary to meet the essential health needs of the patient and the requested increase does not meet assessment and dosage guidelines set by the ABA Coding Coalition and CASP. Finally, without supporting documentation and assessments to justify the increase, there is a lack of documentation that the additional services are not being requested for the convenience of the patient or provider. Moreover, the requested speech therapy services and occupational therapy services are not supported as medically necessary. The records do not include documentation of a thorough assessment and treatment plan. The records do not include a recommendation for speech or occupational therapy from the patients providers to support an indication for these specialty services. Given these findings, the requested additional nine hours per week of direct care ABA services (20 hours per week total), 1.5 hours per week of speech therapy services (2.5 hours per week total), and two hours per week of occupational therapy services (three hours total per week) are 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.