Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.
Treatment: Applied behavioral analysis (ABA) services.

The insurer denied coverage for applied behavioral analysis (ABA) services.
The denial is overturned.

This male reportedly had a diagnosis of Autism Spectrum Disorder and had developmental delays in social communication and social interaction, communication and language delays, repetitive behaviors, difficulties with flexibility, and difficulties with self-care, home living, and community living. He reportedly was first diagnosed with Autism Spectrum Disorder by his pediatrician and started applied behavioral analysis (ABA) services. He reportedly was living with his parents and sister. The request was for continued applied behavioral analysis (ABA) services.
  
The medical records provided enough specific evidence to support that he required this level of care, service, and treatment then. 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 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 social interaction, communication and language delays, repetitive behaviors, difficulties with flexibility, and difficulties with self-care, home living, and community living.  Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder, so treatment is complex and (ABA) applied behavioral analysis is considered medically necessary treatment.  He reportedly made some progress and was expected to make further progress with the continued applied behavioral analysis. As a result, the recommendation is to reverse the previous decision and approve coverage for applied behavioral analysis treatment (ABA) for this patient.  It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for applied behavior analysis (ABA) performed is overturned. Medical Necessity is substantiated.