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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 5 hours per week of 1:1 direct applied behavioral analysis (ABA) services.At issue is whether 5 hours per week of 1:1 direct ABA services are medically necessary to treat the patients condition (autism spectrum disorder) as defined in Health and Safety Code section 1374.72(a)(3)(A) set forth below. 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 highlight that discharge may begin when successive authorizations demonstrate progress has not been made. (CASP). Further, CASP includes social skills within the focused treatment model. All goals outlined in the treatment plan can and should be addressed within a social context. Additionally, Papatola and Lustig outlined criteria for clinicians using ABA to treat autism. The criteria includes health-care 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 records on 1/09/19 indicate that the patient met only 17% of treatment goals for the authorization period 8/17/18 to 2/17/19. On 7/23/19, that the patient only reached 5.5% of treatment goals for authorization period 2/17/19 to 8/16/19. On 8/4/20, that the patient met 30.7% of his treatment goals for authorization period 2/17/19 to 8/16/20. Finally, records on 11/03/20 for the last authorization period show that the patient has only met 33.3% of his treatment goals for the authorization period 8/17/20 to 12/18/20. This highlights that the patient is making minimal progress in 1:1 ABA therapy. Per the current medical evidence, transitioning from 1:1 ABA therapy is appropriate in this setting. Additionally, as the patients goals were almost exclusively social in nature, 1:1 direct ABA does not provide the opportunity to address these concerns. Thus, the requested 5 hours per week of 1:1 direct ABA services are not medically necessary to treat the patients medical condition. Specifically, the requested 5 hours per week of 1:1 direct ABA services are not in accordance with the generally accepted standards of mental health and substance use disorder care. The requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, the requested services are 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.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 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.