Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: Applied behavioral analysis therapy (ABA)  

The insurer denied coverage for applied behavioral analysis therapy (ABA) 

The denial is overturned.

This school-aged boy had developmental delays consistent with Autism Spectrum Disorder. He had social communication and interaction deficits and intellectual delays. He had academic struggles and was unable to connect with others. He could not maintain friendships. He failed to understand how to engage or respond appropriately to others. He was extremely rigid in thinking and desires sameness. He was averse to sensory touch and mundane noise. He had significantly delayed adaptive functioning. He was receiving applied behavioral analysis therapy (ABA) for years. 

His cognitive functioning was assessed using the Comprehensive Test of Nonverbal Intelligence Second Edition (CTONI-2). The test categories came back within the very poor scale range. His communication was in the very low range. The Psychologist noted that the patient would benefit from applied behavioral analysis (ABA) services. 
   
Applied Behavioral Analysis 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 applied behavioral analysis 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 applied behavioral analysis is widely accepted as an effective treatment. 

The National Academy of Sciences reports years of research testifies to the efficacy of time limited focused applied behavioral analysis methods in reducing or limiting specific problem behaviors and teaching new skills to children and adolescents with autism and other developmental disorder. Multiple sources support that applied behavioral analysis 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 individual had significant deficits in language, social communication and interaction, daily living skills, and adaptive functioning and reportedly had a diagnosis of Autism Spectrum and the recommended treatment was applied behavioral analysis therapy (ABA).  This patient had deficits in social communication and interaction and reportedly made progress in the past 2 years with this applied behavioral analysis therapy (ABA). Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder, so treatment is complex and (ABA) applied behavioral analysis is considered medically necessary treatment.  He reportedly made some progress and was expected to make further progress with the continued applied behavioral analysis as a result, the recommendation is to overturned the previous decision and approve coverage for applied behavioral analysis treatment (ABA) for this patient. It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

The insurer's denial of coverage for applied behavioral analysis (ABA) is overturned. Medical Necessity is substantiated.