Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for 10 additional hours of direct 1:1 applied behavior analysis (ABA) therapy (40 hours total). Findings:  The physician reviewer found that the established treatment guidelines set by the Council of Autism Service Providers (CASP) and the ABA Coding Coalition, as well as the medical necessity definition by Papatola and Lustig, the 10 additional hours of direct 1:1 ABA therapy (40 hours total) was and is not medically necessary for treatment of this patient. Both CASP and the ABA Coding Coalition outline treatment guidelines focus on service intensity. The CASP highlighted that, Treatment may vary in terms of intensity and duration, the complexity and range of treatment goals, and the extent of direct treatment provided. The CASP also noted that, The number and complexity of goals should be consistent with the intensity and setting of service provision. The ABA Coding Coalition indicates that, Comprehensive treatment may also be appropriate for patients who engage in harmful and risky behaviors and/or have substantial deficits in adaptive skills that jeopardize their health and safety. Comprehensive ABA programs often involve 30-40 hours of treatment per week. This patients December 2021 treatment plan reported that substantial progress was made during the previous treatment period at a frequency of 30 hours per week. Taking these factors into consideration, the additional 10 hours of 1:1 ABA therapy was not and is not medically necessary for treatment of this patient. In addition, the request also fails to meet the medical necessity criteria outlined by Papatola and Lustig. The authors medical necessity definition includes a) Diagnostic and Statistical Manual 5 (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. Based on the presented information, the request fails to meet criterion (d). Specifically, although ABA is an evidence-based practice, the requested hours are not consistent with established treatment guidelines, and as such the request fails to meet medical necessity. Moreover, the 10 additional hours of direct 1:1 ABA therapy (40 hours total) was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care, and not clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the 10 additional hours of direct 1:1 ABA therapy (40 hours total) was not and is not medically necessary for 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.