Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.
Treatment: ABA Therapy.
The insurer denied the ABA Therapy.
The determination is overturned.

The patient was diagnosed with autism spectrum disorder. He was born at term following an uncomplicated pregnancy, one of twins. His parents noted global developmental delays. He received early intervention services (occupational, physical and speech therapy). He attended a special education preschool. He started to receive applied behavioral analysis (ABA therapy) and had been discharged. ABA therapy resumed . Maladaptive behaviors currently being addressed include touching and talking to others people, and eating habits. The patient tends to fill his mouth with large pieces of food, and eats a lot. He is a picky eater.
Neuropsychological testing was performed. His Full Scale intelligence quotient (IQ) was assessed as being 48 on the Stanford Binet Test. On the Autism Diagnostic Observation Schedule Second Edition (ADOS-2), he met criteria for autism spectrum disorder, Level 2, requiring substantial support. The psychologist noted that he makes poor eye contact. He tends to keep to himself. He exhibits stereotypic and self-stimulatory behaviors, with hand flapping and rocking. He has difficulty following instructions and staying on task. Answers to questions were simple, and limited to 1-2 words. He had echolalia, repeating the last few words said to him by the psychologist. The psychologist recommended continuing ABA therapy, as did his primary care doctor. The patient was evaluated by a physician. He was noted to have been taking Zoloft and Guanfacine for impulsivity in the past, but was no longer on those medications.
ABA progress notes describe that the patient was making progress towards goals, with his performance ranging typically from 75-80% up to 100% of goals met each day.
At issue in this review is whether the requested health service/treatment of applied behavior analysis treatment was medically necessary for this patient.

The requested health service/treatment of applied behavior analysis treatment was medically necessary for this patient.
The patient has been diagnosed with autism spectrum disorder, Level 2, requiring substantial support, by a psychologist using the ADOS -2. He also has moderate intellectual disability, with a Full Scale IQ of 48. Applied behavioral analysis (ABA) therapy was recommended by his psychologist and treating physician. Progress towards goals has been documented.
One of the patient's maladaptive behaviors being addressed in ABA therapy involves crowding his mouth with food, which poses a choking risk. DaWalt et al [1] report the increased risk of fatal choking events in individuals with autism spectrum disorder and intellectual disability. Newcomb et al [2] report that "Children with autism spectrum disorder (ASD) and intellectual disabilities (ID) present with problem behavior at rates disproportionately higher than their typically-developing peers. Problem behavior, such as self-injury, aggression, pica, disruption, and elopement result in a diminished quality-of-life for the individual and family. Applied behavior analysis has a well-established research base, detailing a number of assessment and treatment methods designed to address behavior problems in children with ASD and intellectual disability (ID).
ABA therapy Roth et al [2] performed a meta-analysis on the use of ABA therapy in adolescents with autism spectrum disorder, and found medium-strength efficacy.