Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: Applied Behavioral Analysis (ABA)

The insurer denied coverage for Applied Behavioral Analysis (ABA)

The denial is overturned
 

This young child reportedly has developmental delays in social communication and interaction and has a diagnosis of Autism Spectrum Disorder. It was reported that his communication skills were not age appropriate, he was not able to use language to communicate socially or functionally, would use 1-2 word sentences with minimal detail, and often didn't acknowledge or greet others when engaging in conversation. He reportedly was struggling with one step directions, frequently required maximal prompting, had communication, social and behavioral deficits that prevented him from functioning at an age appropriate level in the environment, was not functionally communicating at an age appropriate level for his needs, was unable to interact socially with others and struggled to follow expectations, frequently had maladaptive behaviors including tantrums when unable to deal with change or given non preferred tasks. It was reported that he had significant regression across all domains in the short period of time he was without further applied behavioral analysis (ABA) therapy treatment. 

Multiple sources support that applied behavioral analysis is an appropriate and effective treatment behaviorally and educationally for autism spectrum disorder children and adolescents. In this case this patient had deficits still with social and communication domains, and deficits in adaptive functioning and behavioral control. He still required this intensity and frequency of services to progress further and also sustain previous gains and for generalization, and to not regress further when not having these services which was what was reported when he stopped this treatment. 

With applied behavioral analysis (ABA) therapy treatment he exhibited ability to maintain low levels of problem behaviors, was able to utilize some functional communication skills with prompting, and tolerate social interactions with family members. It was reported that he will continue to regress which impacts his ability to function in the environment without the same intensity and frequency of applied behavioral analysis (ABA) therapy treatment services. The long term goal was to be able to generalize skills without the need for a behavioral technician and have adequate stabilization of maladaptive behaviors. The requested intensity and frequency of applied behavioral analysis (ABA) services at 30 hours per week for now was considered medically necessary treatment. As a result, the recommendation is to reverse the previous decision and approve coverage for the previously denied requested intensity of applied behavioral analysis (ABA) services at 30 hours per week with tapering of services as outlined when certain objectives and goals were met. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Applied Behavioral Analysis (ABA) is substantiated.