Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive early intervention outpatient program services, as described in the treatment plan. To determine the medical necessity of ABA, research provides guidelines. According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and 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. In this case, the patient has received ABA services for approximately 16 months, and had demonstrated progress in her social deficits and behavioral concerns. The provider was identified as an independent provider while 14 in-network providers have been identified to provide similar ABA therapy to this patient. Studies found that children can make significant social gains attending social skills training with peers with autism. The authors compared a 32-week ABA based social skills group to a wait list control group of 15 children with autism. The study utilized group discrete trial teaching of specific skills appropriate versus inappropriate social behaviors, and taught specific social interaction behaviors utilizing a behavior skills training format. Following the 32-week course, all patients displayed an increase in their social skills and a decrease in problematic behavior. Therefore, while the utilization of typical peers may be desired, it is not necessary for the development of appropriate social skills and decrease in problem behavior. Given these findings, although this patient continues to require ABA services to address social deficits and behavior concerns, these concerns could adequately be addressed by one of the many in-network providers. Since in-network providers can offer similar ABA services, continued services with an independent provider are not medically necessary. Accordingly, the requested intensive early intervention outpatient program services, as described in the treatment plan, are not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychology and a board certified behavioral analyst 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.