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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for  applied behavioral analysis (ABA) therapy at a frequency of 136.5 hours per month. The enrollee presents with diagnoses of autism and Lennox-Gaustat Syndrome. The primary symptomology exhibited as per targeted behaviors from most frequent or most severe exhibited behavior to current presentation, includes tantrums (decreased from 4.5 times per hour to 1.53 times per hour), non-compliance (decreased from 7.5 times per hour to 0.62 times per hour), physical aggression (decreased from 1.3 times per hour to 0.37 times per hour), elopement (decreased from 4 times per hour to 0.37 times per hour), tactile stereotype (decreased from 12 times per hour to 3.05 times per hour), physical stereotype (decreased from 80% of intervals to 27% of intervals), oral stereotypy (70% of intervals to 61% of intervals).  These improvements were made through utilization of interventions via applied behavioral analysis (ABA).  The enrollee was diagnosed with autism at 1.5 years old. For an unspecified duration of time, the enrollee began to obtain 58 hours/week of ABA services per parent report.  Later, the enrollee began to obtain ABA services from a new provider, which offered a reduced allocation of 86 hours per month of ABA services. Following a physician review, the ABA program services were again slightly reduced to 75.8 hours/month, also with the same provider. Similarly, the program then faded again, as a result of the enrollees progress, to 65.5 hours/month. The enrollee then began with a new provider, who also allocated 64.5 hours per month for the enrollee. On a report, the provider requested authorization for increased hours for the enrollee, at a rate of 107.5 hours per month. The enrollee appeared to show progress during his previous ABA treatment services, with reduction in the primary areas of concern including physical aggression and risk of elopement. The other targeted behaviors have also shown improvement from the highest baseline point to the present.  The enrollee is currently receiving occupational and speech therapy. The enrollee has been receiving comprehensive ABA services for over four years. The record indicates significant progress over time, with the majority of gains made at the early onset of treatment, yet most recently the amount of behavioral progress has been minimal. This is aligned with the generally accepted practice guidelines and expectations, as per the medical literature, early intervention can greatly improve a childs development, particularly if the treatment intervention occurs between birth to three years old (36 months) whereby intensive and long-term therapy using ABA principles improves outcomes for many. Intensive and long term refers to programs that provide 25 to 40 hours a week of therapy for one to three years. Forty hours per week for one to three years (average of two years) of ABA is typically the gold standard for patients in the severe range, and this particular enrollee has received as many as 58 hours per week for a period of time with incremental fading based on progress. At this time, the enrollee has not shown evidence of regression, but rather has been able to maintain the current level of progress at the allocated number of hours, which again, is consistent as research has delineated that post three years of ABA early intervention, the amount of effectiveness significantly decreases and the benefit of ABA is minimal, particularly for children over the age of seven.  ABA therapy can be supportive assistance to continue to assist the enrollee in transferring learned skills to the community. However, it is not medically necessary to increase the number of hours. The provider may be requesting increased hours as a result of stagnation in the clients progress. However, this is contraindicated due to research indicating that the enrollees progress, based on age and years of previous interventions, will remain minimal regardless of the number of hours. This is particularly true for this enrollee who also has Lennox-Gaustat Syndrome which has its own related symptomology evidencing behavioral problems, intellectual disability, and developmental delays, which may not necessary, be related to the autism diagnosis. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is licensed 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 similar medical condition.