Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Autism Related Treatment. 
The insurer denied mental health services, ABA therapy. 
The denial is overturned. 

The patient is a male. According to a letter by the patient's Psychiatrist, the patient has diagnoses of Attention Deficit Hyperactivity Disorder (ADHD) combined subtype, oppositional defiant disorder, generalized anxiety disorder and autism spectrum disorder (ASD). He is taking Quillivant 25 milligrams (mg) daily, Lexapro 20mg daily and Intuniv 4mg daily. The psychiatrist describes that the patient has had a partial response to treatment. He continues to have defiant behavior and impulsive actions. His behavior is better at school than at home. He is taught in a multidisciplinary small group setting at school, with specialized teachers. He has an Individualized Education Plan. He receives occupational and physical therapy, counseling and applied behavioral analysis (ABA) therapy at school. At issue in this review is the medical necessity for mental health services (ABA therapy) for this patient.

The health plan's determination is overturned.

The requested Mental Health Services, specifically Applied Behavioral Analysis (ABA therapy) is medically necessary for this patient. He has a diagnosis of autism spectrum disorder, with superimposed ADHD combined subtype, generalized anxiety disorder and oppositional defiant disorder. He is having explosive behavior at home when asked to complete tasks, or when his demands are not met. He has had an incomplete response to pharmacotherapy. He is currently taking 3 psychotropic medications and receiving weekly counseling. ABA therapy is necessary to improve his compliance with daily activities, and to decrease his explosive outbursts. Given his age and increasing size, The patient's behavior could pose a danger to his parents or brother if he becomes aggressive during an outburst. Ongoing parent training will be particularly important, as his behavior is better at school than at home.
The most recent Guidelines on the Identification, Evaluation, and Management of Children With Autism Spectrum Disorder published by the American Academy of Pediatrics [7] describe that "Most evidence-based treatment models are based on principles of ABA. ABA has been defined as "the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior. "The use of ABA methods to treat symptoms of ASD suggests that behaviors exhibited can be altered by programmatically reinforcing skills related to communication and other skill acquisition. Thus, ABA treatments may target development of new skills (e.g., social engagement) and/or minimize behaviors (e.g., aggression) that may interfere with a child's progress."
An extensive body of scientific literature has accrued over the past forty years demonstrating the success of ABA based interventions to decrease problem behavior and increase skills in adults and children with intellectual disabilities and autism. Several meta-analyses indicate that comprehensive ABA intervention leads to medium to large effects in terms of intellectual functioning, acquisition of daily living skills, social functioning and language development in children with autism [2,3].