Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder
Treatment: Applied Behavior Analysis (ABA)
The insurer denied: Applied Behavior Analysis (ABA)
The denial is overturned.

The patient is a school aged male child with autism for whom the family has requested applied behavior analysis services to help with problem behaviors: 10 hours/week of direct therapy, 1.25 hours/week of supervision, 0.5 hours/week of parent training, and 1 hour/week of treatment planning. The health plan approved 7 hours/week of direct therapy, 1 hour/week of supervision, and 1 hour/week of parent training for three months, decreasing to 4 hours/week of therapy, 0.5 hours/week of supervision, and 2 hours/week of parent training, along with 3 hours/month for reassessment and 2 hours/month for treatment planning. Historically, this patient has been receiving ABA (applied behavior analysis) services for over six years, the last year and a half to two years have been over telehealth at 10 hours/week of direct therapy. According to the parents, the patient does better with telehealth than in person. He just 
completed the third grade, where he was in a 12:1:2 class, receiving four 30-minute speech therapy sessions and one 30-minute occupational therapy session per week. Based on the recent functional behavior assessment, there are emerging problem behaviors that have presented since moving back to in-person services. These concerns are interfering with his ability to learn and are affecting his social communication skills with peers and adults. He is engaging in perseverative statements, struggling to be redirected from the statement. New replacement and skill acquisition goals have been added to aid in resolution. The hypothesis is that these statements have developed as a means to avoid others' control over his environment. The 
goals include ways to gain a listener's attention appropriately. He also demonstrates motor stereotypy during instruction, things like hand flapping and vocalizations, concerning for self-stimulatory behaviors. This has impacted his ability to learn during sessions and in the school setting. The hypothesis is that these behaviors function to provide self-stimulation as well as to escape a non-preferred task. The goals include decreasing instances to less than two across 30 consecutive days. Goals have also been added to address core deficits related to social communication and rigidity during social conversations. He continues to show willingness to learn and engage with peers, with added goals to focus on increasing social reciprocity and social pragmatics.
The requested 10 hours/week of direct therapy will provide time to address these emerging maladaptive behaviors as well as provide opportunity to work on core deficits and increase existing skills.

The requested Applied Behavior Analysis (ABA) is medically necessary.

Applied Behavior Analysis is a behavioral approach with a longstanding history of application with children and adolescents on the autistic spectrum. ABA (applied behavior analysis) programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan. The literature supports the utility of this method of intensive intervention particularly for autistic children and adolescents with behavioral issues. ABA (applied behavior analysis) has been successfully used for decades across all environments (home, school, community) to increase communication, reduce problematic behaviors, and reinforce appropriate behaviors.
This male child has made progress with the services that he has been receiving. He recently transitioned from a telehealth platform to in-person services and has developed some maladaptive behaviors as a result. Concurrently, he is demonstrating increased interest in social communication and interaction. The maladaptive behaviors are interfering with successful acquisition of social pragmatic and communication skills. The requested treatment plan with 10 hours/week of direct 
therapy along with the support services and supervision is medically necessary and appropriate to address the current issues and provide opportunity to continue working on core deficits and increase existing skills.