Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested prospective authorization and coverage for applied behavioral analysis (ABA) therapy for 6 months. Findings:  The physician reviewer found that the Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder notes, Focused ABA treatment may involve increasing socially appropriate behavior (for example, increasing social initiations) or reducing problem behavior (for example, aggression) as the primary target. Even when reduction of problem behavior is the primary goal, it is critical to also target increases in appropriate alternative behavior, because the absence of appropriate behavior is often the precursor to serious behavior disorders. Therefore, individuals who need to acquire skills (for example, communication, tolerating change in environments and activities, self-help, social skills) are also appropriate for focused ABA. Similarly, the ABA Coding Coalition reports that in prioritizing treatment targets, the following should be considered: absence of adaptive, social, or functional skills that are fundamental to health, safety, social inclusion, and independence, for example toileting, dressing, feeding, and compliance with medical procedures. In this case, the recommended 15 hours of direct supervision weekly fall within the bounds of focused treatment dosage, as the records note that the patient currently engages in up to 26 instances of problem behavior daily including, screaming, aggression, self-injurious behavior, and tantrums. A treatment plan identifies treatment goals are communicative, adaptive, and social. Further, three hours of supervision weekly align with the standard of the number of supervision hours comprising 20% of the number of direct hours, in this case 15 hours weekly, especially given the frequency and scope of the various challenging behaviors displayed by the insured. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research.  A treatment plan should include, but is not limited to, the assessment process, treatment plan guidelines, supervision guidelines, dosage selection, and discharge criteria. In this case, while the patient appears to have been diagnosed with autism in another country, the diagnosis appeared to be based on the patients presenting to a developmental screener, an interview, and utilization of autism specific measures. In this case, given that the intensity of the services at issue align with the breadth of goals being addressed, the requested medical services are medically indicated. The services at issue are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue  are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue 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. Therefore, ABA therapy for 6 months is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a 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.