Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 110 hours per month of direct applied behavioral analysis (ABA) for treatment of the enrollees autism. Findings:  The physician reviewer found that in this clinical setting, ABA therapy is medically necessary for treatment of the patients medical condition. The medical literature supports ABA therapy as a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients family is requesting continued coverage of ABA therapy to address delays in adaptive, social, behavioral and communication skill sets. A treatment plan has been developed that is consistent with the patients essential health needs and consistent with the diagnosis of autism (targeting behaviors, promoting generalization). ABA, as a treatment option for autism, is evidence based and effective. The providers note that the purpose of ABA therapy in this patients case is to promote independence for the patient by addressing her deficits. The patient appears to have made progress in many areas but continues to demonstrate significant delays in social skills and adaptive skillsets as measured across multiple domains as well as severe behaviors (non-compliance, self-stimulatory behavior, perseveration, scripting, and destructive outbursts). The patient continues to require a high level of behavioral support.  Failure to master these skills not only puts the patient at an increased risk for injury, but also makes it increasingly difficult to be successful in more generalized environments. This patient was approved for 86 hours per month of direct one on one ABA (21. 5 hours per month), which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes (Association for Behavior Analysis International Autism Special Interest Group; Behavior Analyst Certification Board). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week.  Given the medical necessity of ABA in the care of individuals with autism, coupled with the diminished hours of current ABA provision as compared to the research and previous levels of supports, reimbursement and prospective authorization and coverage for 110 hours per month of direct ABA were and are medically necessary. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.