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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) center-based applied behavior analysis (ABA) therapy consisting of 15 hours per week 2:1 (30 hours total) and 255 hours of enhanced supervision over a sixth month period and (2) two technicians to be present during the patients non-emergency medical transportation (NEMT) services to and from the services. Findings:  The physician reviewer found that the patient displayed significant aggressive behaviors during behavioral assessments that occurred by telehealth in the patients home, tackling caregivers to the ground and having to be barricaded the basement due to the intensity of his behaviors. During an in-person assessment in the car, the patient was noted as being aggressive during the transportation, engaging in high-intensity biting, choking, and hitting. The records note that the patients aggression while receiving therapy has prevented clinical staff from aiding in the patients therapy. The ABA Coding Coalition notes that focused ABA treatment plans are appropriate for patients who (a) need treatment only to develop a limited number of key functional skills or (b) have such risky problem behavior that its treatment should be the priority. Examples of problem behaviors requiring focused intervention include, but are not limited to, self-injury, aggression, threats, pica, elopement, feeding disorders, stereotypic motor or vocal behavior, property destruction, noncompliance, disruptive behavior, and dysfunctional social behavior. In prioritizing treatment targets, the following should be considered: behavior that threatens the health or safety of the patient or others or that constitutes a barrier to quality of life, such as severe aggression, self-injury, property destruction, elopement, or noncompliance. The Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder indicate that in some cases, individuals with ASD display co-occurring severe destructive behavior disorders that require focused treatment in more intensive settings, such as specialized intensive-outpatient, day-treatment, residential, or inpatient programs. In these cases, these behavior disorders are given separate and distinct diagnoses. ABA services delivered in these settings typically require higher staff-to-client ratios, such as two to three staff for each patient, close on-site direction from the behavior analyst, and specialized treatment environments such as treatment rooms designed for observation and to keep the patient and the staff as safe as possible. Papatola and Lustig report that ABA services may be medically necessary when a patient meets all of the following criteria: (a) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) autism diagnosis supported by symptoms, (b) symptoms of diagnosis causing impairment, (c) motivation for change exemplified by family involvement, (d) interventions are evidence-based and consistent for type, frequency, and duration of treatment, (e) goals are constructed with patients family, (f) outcomes are measurable, (g) occurs in least restrictive environment, (h) required for purposes other than convenience of patient or provider, (i) measurable reduction in symptoms, (j) symptoms are manageable, and (k) day-to-day functioning has improved over baseline. In this case, the patient meets all of the criteria above. In this case, given that the severity of the patients presentation and level of challenging behavior, the requested services are medically indicated. In this patients case, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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. Therefore, (1) center-based ABA therapy consisting of 15 hours per week 2:1 (30 hours total) and 255 hours of enhanced supervision over a sixth month period and (2) two technicians to be present during the patients NEMT services to and from the services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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.