Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for six hours per week of 1:1 applied behavior analysis (ABA) therapy. Based on the presented information, the treatment guidelines developed by the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, and the medical necessity definition by Papatola and Lustig, requested six hours per week of 1:1 ABA therapy are medically necessary for treatment of this patient. The CASP and ABA Coding Coalition outlined the important elements to consider when determining treatment intensity. The CASP highlighted that, The number and complexity of goals should be consistent with the intensity and setting of service provision. The ABA Coding Coalition indicated that, Focused ABA treatment plans are appropriate for patients who (a) need treatment only to develop a limited number of key functional skills...Examples of key functional skills include, but are not limited to, instruction-following, social skills, communication skills, compliance with medical and dental procedures, sleep hygiene, self-care skills, safety skills, and independent leisure skills. This patients treatment plan details 21 goals, with an emphasis on the functional skills of communication, socialization, and community skills. The requested six hours 1:1 ABA per week, and the number of goals targeted are within the guidelines of focused ABA treatment. In addition, while the patients adaptive behavior composite score on the Vineland-3 is in the adequate range, it is borderline low, and his socialization score is in the low range, which further support that the targeted skills are essential for the patient to navigate his environment. Thus, the requested six hours per week of 1:1 ABA therapy are medically necessary for treatment of this patient. Moreover, the requested six hours per week of 1:1 ABA therapy meets the medical necessity definition outlined by Papatola and Lustig. The authors medical necessity definition includes: a) Diagnostic and Statistical Manual 5 (DSM-5) autism diagnosis supported by symptoms; b) symptoms of diagnosis causing impairment; c) motivation for change exemplified by family involvement; d) interventions are evidence-based and consistent for type, frequency, and duration of treatment; e) goals are constructed with patients family; f) outcomes are measurable; g) occurs in least restrictive environment; h) required for purposes other than convenience of patient or provider; i) measurable reduction in symptoms; j) symptoms are manageable; and k) day-to-day functioning has improved over baseline. As this is the patients first authorization, there is an expected lack of response to intervention. However, the patient meets all of the other criteria to support an indication for the requested services. Furthermore, the requested six hours per week of 1:1 ABA therapy are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Based on the provided information, the requested six hours per week of 1:1 ABA therapy  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.