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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for nine additional hours per week of direct 1:1 applied behavior analysis (ABA) therapy services (CPT 97153) for 26 hours per week total 1:1 ABA services.Findings:  The physician reviewer found that based n the available documentation, the Council of Autism Service Providers (CASP) ABA treatment guidelines, and the definition of medical necessity by Papatola and Lustig, the requested additional nine hours of 1:1 ABA services, for a total of 26 hours per week, are medically necessary for treatment of this patient. The CASP guidelines highlight 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. This patient underwent a reduction in service intensity from 40 hours to 30 hours, then down to 26 hours, and finally down to 17 hours. Treatment with 17 hours led to stagnation of progress on many goals and an increase challenging behaviors. The patient is reportedly engaging in challenging behaviors about 17.68 times per hour, which is roughly once every four minutes. Her treatment plan actively targets 25 goals. Given the scope of treatment and the frequency of the patients challenging behaviors, 26 hours per week of 1:1 ABA services is an appropriate treatment intensity. The patient is also working toward discharge and is following the CASP discharge guidelines by reducing service from comprehensive to focused treatment. In addition, the requested service intensity meets 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. The dosage outlined is designed to meet the essential needs of the patient both in addressing challenging behaviors and the 25 goals listed within the treatment plan. Moreover, ABA is the most effective evidence-based treatment for autism. The requested service intensity and generalized treatment setting are consistent with CASP guidelines and the services are not for the convenience of the patient or provider. For these reasons, the requested nine additional hours per week of direct 1:1 ABA therapy services (CPT 97153), for 26 hours per week total 1:1 ABA services, 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 BCBA, and 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.