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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for 10 additional hours per week of 1:1 applied behavioral analysis (ABA) services. Findings:  The physician reviewer found that Treatment hours are subsequently increased or decreased based on the clients response to treatment and current needs. This patient has been receiving ABA for several years and has made considerable progress during. However, his remaining challenging behaviors are minimal and do not pose an immediate danger to himself or others. The patients services are being delivered in a generalized setting and 25% of the goals are social in nature, which suggests that the patient has developed considerable prerequisite skills to be able to socialize with his peers in a group setting. The patient is currently addressing 25 active goals and continues to make progress. As the patient is making progress, his challenging behaviors are minimal, services are being delivered in generalized locations, and a significant portion of goals are shifting to social skills, the patient should begin the step down of service intensity. Given the patients continued progress and low incidence of challenging behaviors, 30 hours of 1:1 ABA services per week is the appropriate intensity. Moreover, the requested additional 10 hours per week of 1:1 ABA services do not meet the medical necessity definition provided by Papatola and Lustig. 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. This patient does not meet criterion (c). The patient is working on 25 goals with minimal challenging behaviors that are not a danger to himself or others. Services are being delivered in generalized settings and a significant portion of the services are addressing social skills. These indicators suggest that the patient has responded well to ABA therapy and his needs are less significant than reported earlier in treatment. As such, the patient should begin the gradual step down of treatment intensity to match the breadth of treatment that he is currently receiving. The records support that the requested additional 10 hours per week of 1:1 ABA services are not clinically appropriate in terms of frequency. For these reasons, the additional 10 hours per week of 1:1 ABA services (40 hours per week total) were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified 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.