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 all or any of the additional 5 hours of applied behavior analysis (ABA) 1:1, totaling 22 hours per week. At issue is whether all or any of the additional 5 hours of Applied Behavior Analysis (ABA) 1:1 totaling 22 hours per week were medically necessary to treat the patients medical condition. Were and/or are all or any of the additional 5 hours of Applied Behavior Analysis (ABA) 1:1 totaling 22 hours per week medically necessary as defined in Health and Safety code section 1374(a)(3)(A)? California Health and Safety Code section 1374.72(a)(3)(A) states that 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 guidelines on ABA treatment of autism spectrum disorder note that treatment intensity will vary with each patient and should reflect the goals of treatment, specific patient needs, and response to treatment. Reports report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. In this case, the records note that of the 19 skills acquisition goals, the patient was only actively working towards ten goals, many of which were social in nature. The patient was noted to have made progress in the past with fewer hours. While the records note recent difficulty during the pandemic due to the lack of a trained registered behavior technician, this would be considered a lack of educational support rather than of therapeutic support. Therefore, all the additional 5 hours of ABA 1:1 totaling 22 hours per week were not medically necessary for the treatment of this patient. Additionally, all the additional 5 hours of ABA 1:1 totaling 22 hours per week were not and are not medically necessary as defined in Health and Safety code section 1374(a)(3)(A). In this patients case, additional ABA was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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.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 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.