Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parent of a five-year-old male enrollee has requested  applied behavioral analysis therapy for treatment of the enrollees autism.  Findings:  Three physician reviewers found that the patients pediatrician reports that the patient has made significant progress with ABA services in the past and that he has experienced regression since ABA was discontinued. His pediatrician recommended that the patient restart ABA therapy. The patient began receiving ABA therapy on a specific date and it was stopped one year later. Two months after cessation of ABA, the patients family noted that the patient had been using less language, engaging in more repetitive behaviors and play, having more tantrums with aggressive behavior, exhibiting less self-control, having more difficulty with routine changes, requiring up to two hours to eat meals/unable to hold a utensil, and having shorter attention span. Behavioral observation of the patient revealed the patient spoke in 1-3 word phrases only, had poor eye contact and showed lack of initiation in asking for assistance.The medical records indicate that while receiving ABA, the patient met his receptive language goals, improved his eye contact, improved social referencing, improved fine motor skills, gained the ability to indicate hunger and thirst, gained the ability to engage in imaginary play, and made gains in play skills towards age matched peers.   Review of the submitted clinical documentation demonstrates that during his participation in ABA therapy, the patient made significant gains in the three major domains associated with autism: social interaction, language, and repetitive and stereotyped behaviors. These deficits are the focus of therapies used in autism. ABA has a proven record of being effective for treatment of these issues. According to an article by Granpeesheh published in 2009, Twenty years of research on early intensive treatment using applied behavior analysis (ABA) for children with autism has consistently produced robust effects. There appears to be a subset of children whose response to intensive ABA treatments includes achieving a level of functioning that is indistinguishable from typically developing peers. Another common issue experienced by individuals with autism is aggressive behavior and tantrum type behaviors, which appear to be present in this case. These behaviors can be due in part to language problems, problems with social interaction, and problems with schedule rigidity, all of which all associated with autism. The submitted records indicate that during the patients course of ABA, progress was made in decreasing his tantrums and aggression. The patient has been experiencing more physical aggression and tantrums since ABA was stopped. Over the last 4-5 months these behaviors have worsened to the point that the patient has been documented to be physically aggressive with his mother. The literature demonstrates that ABA is beneficial to patients who have aggression and tantrums associated with autism. According to an article by Foxx, ABA is a primary method of treating aberrant behavior in individuals who have autism. The only interventions that have been shown to produce comprehensive, lasting results in autism have been based on the principles of ABA.Behavioral interventions are helpful in many psychiatric conditions due to their ability to be generalized in a patients home, work and school settings. The records provided indicate that this patient was showing generalization in his play behavior with ABA. This is a strong indication that the therapy was effective for him. Additionally, gains in language and IQ are direct prognostic indicators for patients with autism. The literature supports the fact that ABA can be effective in IQ increases. A study by Hayward showed that mean IQ for participantsincreased by 16 points between intake and follow-up. These findings are consistent with previous studies demonstrating the benefits of ABA treatment. In conclusion, the scientific literature supports the use of ABA in this setting. This patient has already benefitted from ABA therapy; as such, continuation of the therapy at a frequency of 20 hours of in-home/community therapy per week is appropriate and indicated. Thus, I have determined the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.