Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Autism Spectrum Disorder 

Treatment:  Applied Behavioral Therapies (ABA) 

The insurer denied the Applied Behavioral Therapies (ABA).The denial was reversed. 

This is a young male patient who was diagnosed at a very early age with developmental delays and Autism Spectrum Disorder.  He had deficits in communication and was mostly nonverbal and used an IPhone to communicate with.  He had ritualized and compulsive behaviors, physical and verbal stereotypies and behaviors, self-injurious behavior including hitting his hand to his forehead.  It was noted that he displayed recent aggression since a reduction in applied behavioral analysis. 

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 to 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 that 40 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 deficits in social communication and interaction, ritualized and compulsive behaviors, physical and verbal stereotypies and behaviors, self-injurious behavior, including hitting his hand to his forehead, and recent aggression since a reduction in ABA.  Goals of treatment included improving communication and adaptive functioning, decreasing maladaptive behaviors, and improving independence and daily skills.  He had regressed after a reduction in these services, including having aggression.  He required these applied ABA services and treatment to further progress and not to regress, which has happened.  This patient required intensive behavioral intervention with applied behavioral analysis therapy, and there were specific target goals and objectives to target behaviors and skills.  Additional goals included improving communication skills in expressing his emotions, decreasing elopement and maladaptive behavior and stereotypies, and decreasing self-aggression, aggression and unsafe behavior.  Still further goals included acceptance of nonpreferred behavior, expressing his physical and emotional status, and decreasing theft.  He required intensive instruction supervision and support.  It was likely that with a lower frequency of ABA services, he would further regress in functioning and behaviors.  Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent, and there are many associated deficits with this disorder; therefore, treatment is complex, and it is medically necessary to have ongoing treatment.  It typically requires a long duration and requires intensive structured and supervised treatment, which ABA can provide. 

Based on the above, the medical necessity for intensive behavioral therapies is substantiated.  The insurer's denial is reversed.