Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder.
Treatment: Autism Related Treatment (Including ABA)-Applied Behavioral Analysis.
The health plan denied ABA therapy as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

Patient is a toddler with a diagnosis of autism spectrum disorder (ASD). Available records include a letter from applied behavioral analysis (ABA) provider which does not include the results of any standardized assessments of the patient, a letter from the provider which does not include any physical examination or medical history information regarding the patient, and a psychological report. The standardized assessments in this report include documentation of Bayley Scales of Infant and Toddler Development, Vineland Adaptive Behavior Scales. An attempt to administer the Leiter-3 was made but was not able to be completed due to his behavior at the time. There is documentation of good effort on the part of the examiner to complete this assessment.
Patient scored in the very low to low range on all the assessments. Patient's primary language is Yiddish and the examiner documents that the examiner is familiar with patient's language and culture and used these skills in applying these standardized instruments. Within the summary of this document is some medical history including that patient was full term via natural delivery. Had an admission to the Neonatal Intensive-Care Unit (NICU) for two weeks at six days and required a feeding tube for six months, a magnetic resonance imaging (MRI) study of the brain reportedly showed hypoplasia of the corpus callosum and mild cerebellar hypoplasia. Patient also has eczema.

The requested treatment of Applied Behavior Analysis (ABA) is not medically necessary for this patient based on the information available.
ABA is one of multiple interventions to manage various symptoms of children with autism spectrum disorder. Appropriate diagnosis, assessment of medical and/or genetic and/or environmental factors is necessary to support that this is the appropriate treatment for an individual patient. Support for ABA being medically necessary as a behavioral intervention for the serious behavior impairments associated with ASD require clinical criteria being met. These criteria include comprehensive evaluation that resulted in a diagnosis of ASD conducted by a licensed physician or licensed psychologist including documentation regarding intellectual impairment, language impairment, association with medical and/or genetic and/or environmental factors and/or another neurodevelopmental, mental, or behavioral disorder. A comprehensive physical examination by the patient's primary care and/or specialty physician such as a neurologist is critically important. These are all clinically necessary for the diagnosis of ASD. For this patient the standard of care clinical criteria as outlined are not met. In the absence of appropriate workup, the risk of providing ABA outweighs the benefits as the patient may have much more substantive improvements with a more appropriate therapy and there is a risk that underlying medical conditions go untreated if this is supplied in the absence of knowledge of other factors influencing his currently impaired status. The patient has documented brain abnormalities for which it appears, according to the documentation submitted for review, no neurologic workup has been conducted to assess underlying medical conditions which may require medication or other interventions including but not limited to a seizure disorder. Once the diagnosis of ASD is established, it is necessary to establish that ABA is the most appropriate and least restrictive treatment necessary for an individual patient.