OHIO DEPARTMENT OF JOB AND F AMIL Y SERVICES BUREAU OF STATE HEARINGS
In the matter of:
ISSUE: Appeal # 1646900 Medicaid 1646900 Compliance Required Decision Date: Request Date: Hearin Officer:
State Hearing Decision
CUYAHOGA MED 07/2512011 02/03/2011 SUSTAINED MICHAEL MCCARTNEY
The appellant's minor child receives Covered Families and Children Medicaid (CFCM) under CareSource, a Managed Care Plan (MCP) designee for the Ohio Department of Job and Family Services (ODJFS). The MCP denied a July 2010 request for prior authorization of Advanced Behavioral Analysis (ABA) therapy due to a determination that the requested service is not medically necessary because it is considered experimental and investigational in the treatment of Pervasive Developmental Disorders (PDD). On 11123/10 a state hearing appeal was sustained. The MCP was required to review additional documentation provided by the appellant's representatives and reconsider the prior authorization request for ABA therapy. The additional
spectrum.
3. The MCP received a prior authorization request for Advanced Behavioral Analysis (ABA) therapy from the child's provider on 7/01110.
4. The MCP's pediatric reviewer denied request on 7/08/10, indicating that ABA is not
"'''AHa", to the treatment not meet
rpf1npctprl a state to "UJ'lJUL~
hearing appeal # 1594246 was assigned, and on 11123/10 the appeal was sustained. (Exhibit 4)
6. The MCP was directed to review additional documentation provided by the appellant's representatives and to reconsider the prior authorization request for ABA therapy.
7. On 12/3/10 the MCP received additional information in support of the position that ABA is an established evidence-based treatment for children with autism spectrum disorders.
8. On 12/811 0 the MCP issued another denial notice (Exhibit 5) & (Exhibit B) which said "Per CareSource Medical Policy, ABA is considered to be experimental and investigational for the treatment of Pervasive Developmental Disorders", and so it does not meet generally accepted standards of medical practice.
9. The 12/8/10 denial notice was also sent to the appellant's pediatrician and the neurobehavioral center.
10. The MCP provided a copy of their medical policy statement (Exhibit C) regarding
"Behavioral Intensive Level Therapy for Treatment of Pervasive Developmental Disorders Including Autism Spectrum Disorders". The medical policy cites studies and findings from sources such as the National Research Council (NRC) from 2001, American Academy of Pediatrics (AAP) from 2007, American Academy of Child and Adolescent Psychiatry (AACAP) from 1999, Scottish Intercollegiate Guidelines Network (SIGN) from 2007, and National Academy of Sciences from 2001.
STATE HEARING DECISION CONTINUATION effectively treat autism".
17. The appellant's representative provided copies ofa U.S. District Court decision out of Oregon, an AAP clinical report on the management of children with autism spectrum disorders, an article in support of why ABA should not be considered experimental, and a
the the ABA. 10)
{,Prl''''rl individual characteristics (age, IQ, and functional impairments) are associated with
positive outcomes.
19. The MCP provided an article on autism spectrum disorders from the Agency for Healthcare Research and Quality (AHRQ), a Hayes rating report on ABA, an article on autism spectrum disorders from a clinical information service called Up to Date. (Exhibit E)
CONCLUSIONS OF POLICY: Policy:
"Medical necessity" is a fundamental concept underlying the Medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, "medically necessary services" are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort.
In addition, a medically necessary service must: meet generally accepted standards of medical
~
ro
U
eXI)ectea outcome; be appropriate to the intensity of service and level of setting; provide unique,
exams must be documented and included and made for the ODJFS
The MCP or its contracting provider must notify members of the appropriate Healthchek exam intervals as specified in Chapter 5101 14 of the Administrative Code.
Healthchek exams are to be completed within ninety
to care
The must show by a preponderance of the evidence that its proposed actions are in accordance with the rules of the Administrative Code. Ohio Administrative Code § 5101 :6-7-01 (C)(l)(c) (2010)
Analysis:
The MCP originally denied a request for ABA therapy in July 2010, stating that ABA is not proven to be etfective for the treatment of Pervasive Developmental Disorders (PDD), and thus does not meet the generally accepted standards of medical practice. A state hearing appeal was sustained, and the MCP was required to review additional evidence from the appellant's
attorney. More evidence was submitted and the prior authorization request was denied again for the same reason.
The most recent denial notice stated, "Per CareSource Medical Policy, ABA is considered to be experimental and investigational for the treatment of Pervasive Developmental Disorders". The MCP referred to medical policy statement which concludes that there is a "lack of definition and guidelines around characteristics of children who would benefits from treatment, lack of evidence-based guidelines for training and credentialing, program content, measurement of success, intensity, duration, and clinical criteria".
STATE HEARING DECISION CONTINUATION
treat autism". Since the appellant has provided clinical evidence supporting the prior
authorization request, along with court decisions contradicting the MCP's position that ABA is experimental, I find the weight of the evidence shows that the ABA therapy is warranted. I recommend the appeal be sustained.
HEARING OFFICER'S RECOMMENDATIONS: Appeal # 1646900 Medicaid
Based on the record me, I find the appeal should be sustained with compliance. The MCP is directed to approve the request for ABA therapy effective the July 2010 request date.
FINAL ADMINISTRATIVE DECISION AND ORDER: Appeal # 1646900 Medicaid
Ohio Administrative Code § 5101 :6-7 -03(B)(1 )(a) (2003) requires compliance with this decision within fifteen calendar days from the date of this decision, but no later than ninety calendar days from the hearing request date. Compliance shall be promptly reported to ODJFS, Bureau of State Hearings, via JFS 04068, compliance form, accompanied by supporting documentation.
Compliance will be achieved when documentation of the approval is submitted to the Bureau of State Hearings.
_t._
Hearing Authority
Si usted cree que esta decision estatal administrativa es erronea, usted puede solicitar una administrativa escribiendo al: Ohio of Job and Services, Bureau of State PO, Box 182825, Columbus, Ohio 43218-2825 0
facsimil (614) 728-9574. Su solicitud debe indicar por usted que la decision administrativa es erronea. Usted ('(wnn"erflr la solicitud de incluida con esta decision. Su solicitud escrita 0 formulario de aIJC;ldl.lVU
dentm de 15 la
Si usted quiere informacion sobre servicios: legales gratuitos pero no sabe cI numero de su oficina local de servicios legales, usted puede Hamar al Ohio State Legal Services Association, gratuitamente, al 1-800-589-5888, para cI numero local.
AMY RAYMOND - BMHC
ODJFS, BUR OF POLICY & PROGRAM SUPPORT P, O. BOX 182709
COLUMBUS, OH, 432182709 NANCY STEPP - CARESOURCE CARESOURCE
CARESOURCE P.O. BOX 8738 DA YTON, OH, 45401 RONDA CRESS
STATE HEARING DECISION CONTINUATION
Appellant's Exhibits:
1 (1
Appendix
4. State hearing appeal # 1594246 decision (9 pages) 5. Denial notice dated 12/8/10 (3 pages)
6. 114111 letter appealing denial and 2115111 denial notice (5 pages) 7. Doctor's credentials (7 pages)
8. PLEAS federal court decision (9 pages) 9. Hummel federal court decision (5 pages)
(8
10. McHenry federal court decision, doctor declaration, AAP clinical report, and articles on ABA (54 pages)
1 L CMS report summary dated 4/1111 (6 pages) CDJFS Exhibits:
A Appeal summary (7 pages)
B. Denial notices dated 12/8/10 (11 pages) C. Medical policy statement (3 pages) D. Medical claims data (4 pages)
E. Article from AHRQ, Hayes rating report on ABA, article from Up to Date (45 pages) Papers and Effects:
