Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for (1) an additional 10 hours of direct outpatient applied behavior analysis (ABA) therapy services (40 hours total) per week, (2) an additional 15 hours of direct outpatient ABA therapy services (40 hours total) per week, and (3) an additional three hours of supervision (eight hours total) per week.The Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder note that treatment may vary in terms of intensity and duration, the complexity and range of treatment goals, and the extent of direct treatment provided. Many variables, including the number, complexity, and intensity of behavioral targets and the clients own response to treatment help determine which model is most appropriate. The CASP guidelines further emphasize that, Comprehensive ABA refers to treatment of the multiple affected developmental domains, such as cognitive, communicative, social, emotional, and adaptive functioning. Maladaptive behaviors, such as noncompliance, tantrums, and stereotypy are also typically the focus of treatment. Medical literatures report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research. In this case, the records note that a treatment plan included 29 skills acquisition goals, spanning the domains mentioned above, along with steps to address challenging behaviors including aggression, self-injury, and tantrums. While most of the goals are not complex in nature, given the sheer volume and breadth of programming to be addressed, coupled with the high number of the patients episodes of challenging behaviors daily, a higher treatment intensity is medically indicated. Therefore, (1) an additional 10 hours of direct outpatient ABA therapy services (40 hours total) per week and (2) an additional 15 hours of direct outpatient ABA therapy services (40 hours total) per week were and are medically necessary for the treatment of this patient. The additional 10 hours of direct outpatient ABA therapy services (40 hours total) per week and (2) an additional 15 hours of direct outpatient ABA therapy services (40 hours total) per week were and are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. An additional 10 hours of direct outpatient ABA therapy services (40 hours total) per week and (2) an additional 15 hours of direct outpatient ABA therapy services (40 hours total) per week were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.The CASP guidelines note, The ratio of case supervision hours to direct treatment hours reflects the complexity of the clients ASD symptoms and the responsive, individualized, data-based, decision-making that characterizes ABA treatment. A number of factors increase or decrease case supervision needs on a shorter- or longer-term basis. These include: treatment dosage/intensity; barriers to progress; issues of client health and safety (for example, certain skill deficits, dangerous problem behavior); the sophistication or complexity of treatment protocols; family dynamics or community environment; lack of progress or increased rate of progress; changes in treatment protocols; transitions with implications for continuity of care. In this case, given the complexity of the goals identified and the patients previous level of skill acquisition in the eight years that she has accessed ABA services, five hours of weekly supervision is appropriate and an additional three hours weekly of supervision are not medically indicated. Therefore, (3) an additional three hours of supervision (eight hours total) per week were not and are not medically necessary for the treatment of this patient. An additional three hours of supervision (eight hours total) per week were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration.Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.