Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism.

Treatment: An additional 15 hours per week for 26 weeks of applied behavioral analysis therapy for autism.

The insurer denied coverage for the additional 15 hours per week for 26 weeks of applied behavioral analysis therapy for autism.

The denial is overturned. 

This patient is a female child with a diagnosis of autism with developmental delays in social interaction and communication, expressive and receptive language, restricted and repetitive behaviors, and delays in adaptive functioning. The patient exhibited tantrums, noncompliance, and problems with shared attention. The patient reportedly was receiving applied behavioral analysis therapy and the insurer approved 28 hours of applied behavioral analysis therapy and denied the additional 15 hours per day of applied behavioral analysis therapy requested. 

This reviewer disagrees with the decision to deny the request for the additional applied behavioral analysis therapy for a total of 40 hours per week of applied behavioral analysis therapy for this patient as the medical records provided and current literature support the use of 40 hours per week of applied behavioral analysis therapy for the treatment of autism spectrum disorder.  

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. The New York State Department of Health reportedly recommends that applied behavioral analysis and behavioral intervention strategies should be included as inpatient elements of any intervention program for children with autism. 

In this case, this patient had severe deficits still with social and communication domains and deficits in adaptive functioning and behavioral control, as well as inflexibility and stereotypic and repetitive behaviors and required more frequency and intensity of this applied behavioral analysis therapy. The requested 40 hours per week of applied behavioral analysis therapy appeared to be medically necessary treatment.  This intensity and frequency of services appeared to be medically necessary for this patient to progress further and also sustain previous gains and for generalization.  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 it typically requires a long duration with intensive and sustained structured and supervised treatment.  If this patient did not receive the requested level of treatment for applied behavioral analysis therapy at 40 hours per week, the patient likely would not progress enough in socialization, communication, and behavioral control. 

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

The carrier's denial of coverage for the additional 15 hours per week for 26 weeks of applied behavioral analysis therapy for autism should be overturned. The medical necessity is substantiated.