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 Increase in applied behavior analysis (ABA) services including 25 hours per week of direct intervention (CPT 97153), four hours a month of group social skills (CPT 97154), 18 hours a month of supervision (CPT 97155), four hours a month of caregiver training (CPT 97156), two hours per month group caregiver training (CPT 97157), and three hours total report writing (CPT 90889)). Per Health and Safety code section 1374(a)(3)(A), Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. The Council of Autism Service Providers (CASP) guidelines indicate that, Treatment dosage, which is often referenced in the treatment literature as intensity, will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. The request fails to meet the CASP guidelines, as it is not consistent in type, frequency, and duration of treatment with scientifically based guidelines. In this case, the provider noted that the scope of the patients progress could not be determined. The records fail to document the extent of any regression that has occurred. 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 this definition, the patient fails to meet (a) and (c). Specifically, due to the lack of utilization and inability to ascertain progress during the previous authorization period, the records do not support than an increase will meet the essential health needs of the patient. All told, the requested increase in ABA services including 25 hours per week of direct intervention (CPT 97153), four hours a month of group social skills (CPT 97154), 18 hours a month of supervision (CPT 97155), four hours a month of caregiver training (CPT 97156), two hours per month group caregiver training (CPT 97157), and three hours total report writing (CPT 90889)) to treat the patients mental health or substance use disorder is not medically necessary as defined by Health Safety Code section 1374(a)(3)(A).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.