Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder
Treatment: Applied Behavior Analysis (ABA) Behavior Assessment (97151 12 units)
The insurer denied:  Applied Behavior Analysis (ABA) Behavior Assessment (97151 12 units)
The denial is overturned

The patient is a young school aged female who was diagnosed with autism spectrum disorder. She was reported to have been receiving applied behavioral analysis (ABA) therapy previously. The patient's provider is requesting 12 units of behavioral reassessment (97151) for functional behavioral assessment prior to continuation of ABA (applied behavioral analysis) therapy. The patient was noted to have had a change in coverage. The requested behavioral assessment (97151 - 12 units) was noted to have been previously denied as not medically necessary, as it was indicated that a formal diagnosis of autism spectrum disorder was not made, and the patient was using appropriate diagnostic instruments. The patient's provider is appealing the previous denial with clinical documentation indicating a diagnosis of autism spectrum disorder. The clinical information provided indicates that appropriate diagnostic instruments including the Autism Diagnostic Interview (ADI-R), Child Behavior Checklist (CBCL), and Behavior Assessment System for Children (BASC-3) were noted to have been administered, in addition to parent interviews and direct behavioral observation in order to make the diagnosis of autism spectrum disorder. The patient was noted to have significant speech delay. There was no indication of any difficulties with vision or hearing. The patient was not prescribed any psychotropic medications. The patient was administered the Vineland Adaptive Behavioral Scales (Vineland-3) which showed an adaptive behavior composite score of 55, indicating significant impairments in communication, daily living skills and socialization. The patient was reported to have significant impairments in social communication, joint attention, and sensory intolerance. She was also noted to have repetitive stereotypical behaviors and restricted interests. The patient was noted to have difficulties with transitions and nonverbal communication. She was noted to have behavioral dysregulation including agitation, aggression, and irritability.

The requested Applied Behavior Analysis (ABA) Behavior Assessment (97151 12 units) were found to be medically necessary.

The patient continues to have significant symptoms including significant impairments in social communication and behavioral dysregulation. She was noted to have significant impairments in age-appropriate activities of daily living. There was no indication that the patient was at imminent risk of harm to self or others. The behavioral assessment was requested in order to determine a treatment plan which was to be administered in a setting that is compatible with the patient's needs. The treatment plan that would be finalized following the assessment will address communication and language functioning, repetitive behaviors, social interactions, and disruptive behaviors in addition to co-morbid medical and psychiatric conditions. The ABA (applied behavioral analysis) assessment and therapy is provided by board certified professionals credentialed for independent practice of ABA (applied behavioral analysis). There is significant evidence in current peer reviewed, evidence-based medical literature to indicate the clinical benefit of ABA (applied behavioral analysis) therapy for treatment of autism spectrum disorder. Clinical documentation provided does not indicate any ambiguity in the diagnosis of autism spectrum disorder in this patient. The functional behavioral assessment prior to the determination of a treatment plan for ABA (applied behavioral analysis) therapy is an essential component of treatment. Therefore, based on current peer reviewed, evidence-based medical literature, requested behavioral reassessment (97151) for functional behavioral assessment prior to continuation of applied behavioral analysis (ABA) therapy was found to be appropriate and medically necessary in this patient.