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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for additional 30 hours per week of direct applied behavior analysis (ABA) services (40 hours per week total) and an additional six hours per week of ABA supervision (eight hours per week total) for the first time period, and/or an additional 35 hours per week of direct ABA services (40 hours per week total), additional seven hours per week of ABA supervision (eight hours per week total), and an additional two hours per week of caregiver training (four hours per week total) for the second time period. The Council of Autism Service Providers (CASP) noted that, Treatment dosage, which is often referenced in the treatment literature as intensity, will vary with each client and should reflect the goals of treatment, specific client needs, and response to treatment. Given this patients low Vineland scores, the 20 goals being addressed, and the three challenging behaviors being tracked, a regimen of 40 hours per week of direct ABA services is consistent with current guidelines. The records support that the patient has made progress with ABA services. Further, the CASP and ABA Coding Coalition guidelines highlight that supervision for each case must be responsive to individual client needs, two hours for every 10 hours of direct treatment is the general standard of care. Thus, eight hours of supervision per week and four hours per week of parent training are also supported as medically necessary.In addition, the requested services meet the medical necessity criteria outlined 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. For this patient, the ABA services are required to meet essential health needs, as outlined in the treatment authorization request. ABA treatment is consistent with the diagnosis of autism and the requested intensity of direct ABA services and supervision are within the established guidelines. Moreover, the services are not for the convenience of the patient or provider, and the services are being rendered in the least restrictive treatment environment. Given these findings, the additional 30 hours per week of direct ABA services (40 hours per week total) and an additional six hours per week of ABA supervision (eight hours per week total) for the first time period, and an additional 35 hours per week of direct ABA services (40 hours per week total), additional seven hours per week of ABA supervision (eight hours per week total), and an additional two hours per week of caregiver training (four hours per week total) for the second time period were and are medically necessary for 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 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.