Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention Deficit Disorder
Treatment: Applied Behavior Analysis 
The insurer denied Applied Behavior Analysis 
The determination is upheld.

This is a male patient who was evaluated in the Developmental Pediatrics Division. The provider described that the patient fulfilled criteria for Attention Deficit Hyperactivity Disorder, Inattentive type, with cognitive and language delays. The Autism Diagnostic Observations Schedule (ADOS) was administered at the last visit. He scored 5 and did not meet criteria for a diagnosis of autism spectrum disorder. The provider stated: "the patient's social difficulties are explained by his language and cognitive delays and are not due to autism."
His developmental milestones were significantly delayed. He had tantrums, but always with identifiable triggers.
He attended an early intervention program and subsequently a special education preschool and grade school.
He receives occupational therapy, speech therapy and counseling. He started to receive applied behavioral analysis (ABA) therapy. Records from his prior ABA therapy were not provided. He was given a trial of a stimulant medication for his attention deficit hyperactivity disorder (ADHD), but his parents described that he was hyperemotional, nervous and jittery. His teachers did not notice significant improvement in his focus, so the medication was stopped.
A telehealth neuropsychological evaluation was performed. The patient's parents described that he struggled with transitions, and had difficulty with social skills and communicating with others. The Childhood Autism Rating Scale - Second Edition (CARS2) was administered, together with the Vineland Adaptive Behavior Scales. The patient's score on the CARS2 was felt to be consistent with Mild-Moderated Autism Spectrum Disorder. He scored in the Low range in all domains on the Vineland. The patient's attention was poor, and only an estimate of his level of function could be obtained on the Weschler Intelligence Scales for Children, Fifth Edition (WISC-5). Ongoing ABA therapy was recommended, including 20 hours per week of direct ABA, 2 hours per week each of direct supervision, behavior treatment planning and parent training, with 6 hours of re-assessment per authorization period.
At issue in this review is whether the requested health service/treatment of Applied Behavior Analysis medically necessary for this patient.

The requested health service/treatment of Applied Behavior Analysis is not medically necessary for this patient.
Serial evaluations described that the patient did not meet diagnostic criteria for autism spectrum disorder. The provider described that the patient had global developmental delays and attention deficit hyperactivity disorder (ADHD) - inattentive type.
An evaluation was conducted by telehealth, lacked detail regarding early developmental milestones, and omitted detailed direct evaluation of the patient's cognition and behavior.
At best, there is limited support in the medical literature for the efficacy of ABA therapy in older children, even those with autism spectrum disorder. The evidence supporting a diagnosis of autism spectrum disorder for this patient is lacking. He is not described as having any aggressive or maladaptive behaviors which might be addressed by ABA therapy.
Roth et al [1] performed a meta-analysis on the use of ABA therapy in adolescents with autism spectrum disorder, and found medium-strength efficacy.