Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 150.5 hours per month of applied behavioral analysis (ABA) therapy; with up to 124 hours per month to be provided in the pre-school setting and 26.5 hours to be provided in the home, clinic, or community setting. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism, food protein induced enterocolitis syndrome, and mast cell activation disorder. At issue in this case is whether the requested 150.5 hours per month of applied behavioral analysis (ABA) therapy; with up to 124 hours per month to be provided in the pre-school setting and 26.5 hours to be provided in the home, clinic, or community setting; is medically necessary for treatment of the enrollees behavioral health condition. In the case of the patient, while intensive ABA therapy is indeed appropriate, the setting of implementation must be considered. The BACBs practice guidelines for ABA therapy specifically state that coverage of ABA treatment for autism spectrum disorder (ASD) should not supplant responsibilities of educational or governmental entities. Furthermore, ABA treatment must not be restricted to specific settings but instead should be delivered in those settings that maximize treatment outcomes for the individual client. It appears from the progress report included that the patient has several goals targeted at addressing his social communication deficits; such as increasing peer play and play skills, following directions, and waiting before receiving desired items. These goals will be best targeted in natural setting with access to same-age peers, such as school. The patient may indeed benefit from one to one support throughout the entire school day. However, it is not the responsibility of the health plan to provide such comprehensive support. The goals listed in the patients treatment plan do not warrant full-day support in order to be sufficiently targeted. Therefore, based on the goals cited for the patient in the provider report, the 108 hours currently approved for therapy are sufficient. However, the patient should receive 60 hours per month of direct ABA therapy to be utilized in the school setting (approximately 3 hours per day while at school). The remainder of approved hours should be utilized to address goals in home and community settings, with additional hours for supervision and case management as appropriate. It is the responsibility of the school to provide the individualized support and assistance requested for the patient throughout the entire school day; with continued collaboration with the ABA provider occurring regularly.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients behavioral health condition. Therefore, the Health Plans denial should be overturned.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.