Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder (ASD)
Treatment: Neuropsychological Testing
The insurer denied: Neuropsychological Testing
The denial is upheld.

The patient is a toddler male. Six months ago, a clinical psychologist evaluated the patient for autism spectrum disorder (ASD). The psychologist relied on parent interview; Social Responsiveness Scale, Second Edition (SRS-2); Autism Diagnostic Observation Schedule-2nd Edition (ADOS-2), Module 1; and the Wechsler Preschool and Primary Scales of Intelligence, Fourth Edition (WPPSI-IV). She reviewed previous testing and described his skills adequately. The patient's total score (not documented) on the ADOS-2 (Autism Diagnostic Observation Schedule-2nd Edition) did not meet the cutoff for autism for autism spectrum. The ADOS-2 (Autism Diagnostic Observation Schedule-2nd Edition) comparison score of 1 was "Minimal-to-No Evidence of ASD [autism spectrum disorder]." The ADOS-2 (Autism Diagnostic Observation Schedule-2nd Edition) narrative describes a neurotypical child who has no symptoms of autism spectrum disorder. His WPPSI-IV (Wechsler Preschool and Primary Scales of Intelligence, Fourth Edition) Full-Scale IQ (intelligence quotient) of 99 is solidly in the average range of 85 to 115. Despite the patient having no symptoms of autism spectrum disorder, his mother's input on the SRS-2 (Social Responsiveness Scale, Second Edition) indicated that she perceived him as having severe autism spectrum disorder-like symptoms. The psychologist reviewed the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) diagnostic criteria for autism spectrum disorder, but based her review solely on parent report, ignoring his ADOS-2 (Autism Diagnostic Observation Schedule-2nd Edition) performance and seeking no teacher input. Despite that, and despite the patient having no symptoms of autism spectrum disorder, based solely on parent report, she diagnosed the patient with autism spectrum disorder. 

The requested health service is not medically necessary.

Autism spectrum disorder (ASD) is a clinical diagnosis. It should be suspected in children with abnormalities in social interaction, deficits in communication, and restricted repetitive behaviors, none of which is demonstrated in this patient. Clinicians must rely on their clinical judgment, aided by the guides to diagnosis described below (1, 2, 3). Evaluation for autism spectrum disorder should include a comprehensive assessment, preferably by an interdisciplinary team led by a provider who has sufficient training and expertise to evaluate and manage autism spectrum disorder for example (e.g.), clinical child psychologist, board-certified child psychiatrist, board-certified child neurologist, board-certified developmental-behavioral, or board-certified neurodevelopmental pediatrician), and is able to discern subtle differences between autism spectrum disorder and confounding diagnoses (e.g., global developmental delay/intellectual disability, severe language delay/disorder, generalized anxiety disorder, and attention-deficit/hyperactivity disorder [ADHD]). 
In this case, the psychologist relied on parent interview alone to diagnose the patient with autism spectrum disorder, fully ignoring his performance on the ADOS-2 (Autism Diagnostic Observation Schedule - 2nd Edition). The diagnosis must be confirmed by reviewing the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for autism spectrum disorder or the International Disease Classification, 10th Revision (ICD-10). This requires a thorough description of which criteria are met and why, rather than a blanket statement that criteria are met. In this case, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition requires that the patient demonstrate symptoms across all settings. This is not the case with this this patient. Only his mother describes him as having autism spectrum disorder-like symptoms. The ADOS-2 (Autism Diagnostic Observation Schedule - 2nd Edition) effectively rules out the diagnosis, and the psychologist failed to obtain input from the patient's teacher. Because autism spectrum disorder is a neurological disorder, it is not possible that a child can demonstrate symptoms only with the mother but not during the ADOS-2 (Autism Diagnostic Observation Schedule - 2nd Edition). Furthermore, despite both the mother and teacher raising concern for attention-deficit/hyperactivity disorder, the psychologist suggested (incorrectly) that he is too young for that diagnosis. This child's evaluation failed to adhere to the above guidelines. Thus, it was not medically necessary, appropriate, or standard of care.