Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder. 
Treatment: Applied Behavior Analysis (ABA) Behavior Assessment (97151x12 units). 

The insurer denied: Applied Behavior Analysis (ABA) Behavior Assessment (97151x12 units). 

The denial is upheld. 

This patient is a school aged female. Three years ago, a clinical psychologist evaluated the patient. On the Wechsler Intelligence Scale for Children - Fifth Edition (WISC-V) her Full-Scale IQ was 69.  To assess for autism spectrum disorder (ASD), the psychologist relied on parent interview (Autism Diagnostic Interview, Revised [ADI-R]), brief unstructured clinical observation, and two behavioral questionnaires unrelated to autism spectrum disorder: the Screen for Child Anxiety-Related Disorders (SCARED) and a broad behavioral questionnaire (Child Behavior Checklist - CBCL). The psychologist failed to directly assess the patient's social-communication, play, and behavior using a semi-structured play-based diagnostic clinical tool (e.g., Autism Diagnostic Observation Schedule-2nd Edition [ADOS-2]). The psychologist suggested that that the patient met the Diagnostic and Statistical Manual of Mental Disorders 
Fifth Edition (DSM-5) diagnostic criteria for autism spectrum disorder, but failed to address her low intelligence (i.e., intellectual disability) and why that could not better account for the patient's autism spectrum disorder-like symptoms. 
No evaluation for applied behavior analysis (ABA) therapy with a board-certified behavior analyst (BCBA) was provided. No applied behavioral analysis goals are provided and there is no evidence of improvement. 

Applied behavioral analysis therapy is not medically necessary. 

Initial applied behavioral analysis therapy is appropriate when a patient meets all the following [Reichow 2018, Volkmar 2018, Stevenson 2019, Odom 2020, Rodgers 2020, Anderson 2021, Morris 2021, Maffei-Almodovar 2022]:
- Proposed treatment is clinically appropriate as indicated by ALL the following:
** Patient has a confirmed diagnosis of autism spectrum disorder (ASD) defined as follows: 
* Evaluated by a qualified diagnostician, defined as any of the following (practicing alone or as part of an interdisciplinary team): 
- Board-certified developmental-behavioral pediatrician 
- Board-certified neurodevelopmental pediatrician 
- Board-certified child neurologist 
- Doctoral-level clinical child psychologist (i.e., PsyD or PhD) [Met] 
- Licensed school psychologist 
- Clinical child psychiatrist 
* Diagnosis based on ALL the following: 
- Parent / caretaker interview [Met] 
- Unstructured, informal clinical observation [Met] 
- Semi-structured clinical observation using the Autism Diagnostic Observation Schedule-2nd Edition (ADOS-2) with a module appropriate to the child's language level [Not met] 
- Patient meets Diagnostic and Statistical Manual of Mental Disorders Fifth Edition diagnostic criteria, which requires confirmation of both the following:
* That global developmental delay or intellectual disability does not better explain the patient's symptoms [Not met. The patient's Wechsler Intelligence Scale for Children - Fifth Edition Full-Scale IQ of 69 indicates intellectual disability. The psychologist failed to address this.] 
* That language delay or disorder does not better explain the patient's symptoms [Not met. There is no documentation of the patient's performance on standardized intelligence testing.] 

In a systematic review of observational studies evaluating diagnostic accuracy in children less than 6 years of age who underwent multidisciplinary evaluation for autism spectrum disorder, the Autism Diagnostic Observation Schedule-Second Edition was the most sensitive diagnostic tool (94 percent compared with 80 percent for Childhood Autism Rating Scale (CARS) and 52 percent for Autism Diagnostic Interview, Revised) [Randall 2018]. As such, it is recognized as the reference standard. 
- Proposed treatment and monitoring plan is appropriate as indicated by ALL the following: 
[None of the following criteria are met because no formal applied behavioral analysis evaluations were provided.] 

In conclusion, the request for applied behavioral analysis therapy is not medically necessary, appropriate, or standard of care because the patient fails to meet the above criteria.