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 of hours of 1:1 applied behavioral analysis (ABA) therapy from 15 hours to 22 hours per week. Findings:  The physician reviewer found that requested services fail to meet multiple elements of Papatola and Lustigs definition of medical necessity. 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. Per the records provided for review, this patients provider has listed several goals that do not address the symptoms of autism. These goals include housekeeping, feeding pets, cleaning surfaces, and cooking. Although each of these goals requires the patient to work on his ability to follow directions, the goals do not explicitly address the core symptoms of autism such as socialization and communication deficits, or repetitive behaviors. Thus, the requested services do not meet criterion (b). In addition, the provider identifies that the reason for the increase in support hours is for the patient to access additional support while school is closed. However, the services need to be indicated due to the severity of the patients symptoms, not because the patient is more available for treatment. An increase in hours when school is unavailable fails to meet criterion (d), as the increase is due to convenience of the patient. Moreover, the requested increase in 1:1 ABA hours is not consistent with the Council of Autism Service Providers (CASP) recommendations. The CASP highlight the requirements for focused levels of treatment intensity typically includes 10-25 hours per week 1:1 ABA therapy. Focused ABA is appropriate for a limited number of functional skills. Given that several of this patients goals identified in the authorization request are not medically necessary, and low rates of problem behaviors are documented, the current 15 hours of 1:1 ABA per week is appropriate. For these reasons, the requested increase in hours of 1:1 ABA therapy from 15 hours to 22 hours per week is 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.