Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) (30 hours total) and 16 hours per month supervision by a B.C.B.A. (24 hours total) and 0.5 hour per month reassessment (one hour total). The Council of Autism Service Providers (CASP) guidelines on ABA treatment of autism spectrum disorder highlight the difference between focused treatment, ten to 25 hours weekly, and comprehensive treatment, 30 to 40 hours weekly. Specifically, the guidelines note that comprehensive treatment 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. Although there are different types of comprehensive treatment, one example is early intensive behavioral intervention where the overarching goal is to close the gap between the clients level of functioning and that of typically developing peers. These programs tend to range from 30 to 40 hours of treatment per week (plus direct and indirect supervision and caregiver training). Initially, this treatment model typically involves 1:1 staffing and gradually includes small-group formats as appropriate. Comprehensive treatment may also be appropriate for older individuals diagnosed with autism spectrum disorder, particularly if they engage in severe or dangerous behaviors across environments. 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. The ABA Coding Coalitions model coverage policy notes that, `Treatment may vary in intensity, duration, the complexity and range of treatment goals, the extent of direct treatment provided, and other dimensions. Although there is a continuum of ABA treatments, they can generally be categorized as focused or comprehensive. Many variables - including the number, nature, and complexity of behavioral targets and the patients history and response to treatment - determine which model is appropriate. In this case, the submitted treatment plan includes a few areas of treatment such as social emotional reciprocity, fixated interests, and adaptive skills, that have been broken into multiple goals. The records noted that the patient was progressing on multiple goals. He presented with minimal challenging behavior, with few instances of aggression, self-injurious behavior, or self-touching. While the records note that the patient engaged in some stereotypy, this behavior was noted as being due to increased staff distance between the provider and the patient. The records indicate that the patient had the skill to complete tasks and was requiring less support over time. Papatola and Lustig report that ABA services should be consistent for type, frequency, and duration of treatment, and required for purposes other than convenience of patient or provider. In this case, several goals appear to be related to the patients employment, including cleaning workstations, preparing and eating food at work, and completing work-related tasks such as stacking items. The records suggest that ABA services are being provided for the patients convenience, serving as job coaching rather than therapy. Given the lack of complexity in goals, the number of goal areas, and the minimal nature of the patients challenging behavior, the services at issue are not medically indicated. In this patients case, 20 hours per week of direct ABA (30 hours total) and 16 hours per month supervision by a B.C.B.A. (24 hours total) and 0.5 hour per month reassessment (one hour total) were not and are not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were and are 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, 20 hours per week of direct ABA (30 hours total) and 16 hours per month supervision by a B.C.B.A. (24 hours total) and 0.5 hour per month reassessment (one hour total) were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.