Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional four hours per week of applied behavior analysis (ABA) services, for a total of 25 hours per week. The Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder note that the number and complexity of goals should be consistent with the intensity and setting of service provision. In this case, the patients treatment plan includes nine challenging behaviors and 42 skills acquisition goals that are being targeted. While the patient is noted as making progress in many of those goals, and close to meeting some, the sheer volume of behaviors and skills being targeted warrants the requested intensity of 25 hours per week. The ABA Coding Coalition details the required treatment components of ABA services, including the ongoing collection, quantification, and analysis of graphed direct observational data on all treatment targets. In this case, many of the goals being targeted included graphic representation, including the Vineland-3, and for goals that were not graphed, an explanation of the amount of progress that had been made was included, usually as a percentage or fraction. The ABA coding coalition further notes that ongoing careful case supervision and clinical direction by a professional behavior analyst that includes but is not limited to coordinating care with other providers; directing the implementation of the treatment plan by behavior technicians, caregivers, and other supervisees; reviewing patient progress data frequently; and modifying treatment protocols and the treatment plan as indicated by the data. In this case, the B.C.B.A. is the most qualified individual to set the treatment intensity, being thoroughly involved in the patient's care and fluent with the data used to monitor progress. Papatola and Lustig report that ABA services may be medically necessary when a patient meets all of the following criteria: (a) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) autism diagnosis supported by symptoms, (b) symptoms of diagnosis causing impairment, (c) motivation for change exemplified by family involvement, (d) interventions are evidence-based and consistent for type, frequency, and duration of treatment, (e) goals are constructed with patients family, (f) outcomes are measurable, (g) occurs in least restrictive environment, (h) required for purposes other than convenience of patient or provider, (i) measurable reduction in symptoms, (j) symptoms are manageable, and (k) day-to-day functioning has improved over baseline. In this case, the submitted treatment plan covered each of these elements and the records included ample data and updates on the patients progress. In this patients case, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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, an additional four hours per week of ABA services, for a total of 25 hours per week, are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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.