Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
Treatment: Applied Behavior Analysis (ABA) Behavior Identification Assessment, 97151, 12 units
The insurer denied coverage for Applied Behavior Analysis (ABA) Behavior Identification Assessment, 97151, 12 units.
The denial is overturned.

The insurer denied coverage for Applied Behavioral Analysis (ABA), for codes 97151. They stated that there was no comprehensive evaluation submitted.

This child has a diagnosis of autism spectrum disorder. The child has delayed language, social interaction, and maladaptive and stereotypic behaviors, cannot interpret social cues or norms, does not initiate, or respond to social interaction, has abnormal approach to peers and does not understand relationships, has difficulty adjusting behavior to suit various social contexts, and is not engaging in sharing or taking turns. The child fails to produce functional language to express needs and wants, has abnormal eye contact and body language, cannot comprehend directions with multiple objects, is unable to complete tasks independently, has delayed latency to transitions, insists on sameness, is resistant to changes in routine, and is disruptive in group settings. The patient has significant impairment in social and other areas of functioning. The recommendation is for continued Applied Behaviors Analysis (ABA), as it was previously approved by past insurance.

ABA according to the American Academy of Child and Adolescent Psychiatry is an effective behavioral treatment for autism spectrum disorder children and has been shown to significantly facilitate acquisition of language, social skills, and improve behavior through early and sustained intervention. The American Academy of Pediatrics reports that the efficacy of ABA is well documented through 5 decades of work and has shown substantial sustained gains in adaptive, academic, language, social, and behavioral functioning and better reported outcomes. The National Institute of Mental Health reports that ABA is widely accepted as an effective treatment. The National Academy of Sciences reports that 40 years of research testifies to the efficacy of time limited focused ABA methods in reducing or limiting specific problem behaviors and teaching new skills to children and adolescents with autism and other developmental disorders. Multiple sources support that ABA is an appropriate and effective treatment behaviorally and educationally for autistic spectrum disorder individuals with social delays, language and communication delays, and difficulties in adaptive functioning. In this case this patient reportedly had developmental delays in social interaction and communication, deficits in social and emotional reciprocity, delayed language, social interaction, and maladaptive and stereotypic behaviors, could not interpret social cues or norms, did not initiate or respond to social interaction, had abnormal approach to peers and did not understand relationships, had difficulty adjusting behavior to suit various social contexts, and was not engaging in sharing or taking turns, failed to produce functional language to express needs and wants, had abnormal eye contact and body language, could not comprehend directions with multiple objects, was unable to complete tasks independently, had delayed latency to transitions, insisted on sameness, was resistant to changes in routine, and was disruptive in group settings.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Applied Behavior Analysis (ABA) Behavior Identification Assessment, 97151, 12 units, is substantiated.