Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder (ASD).
Treatment: Applied behavior analysis (ABA) assessment (97151, 12 units).
The insurer denied coverage for applied behavior analysis (ABA) assessment (97151, 12 units).
The denial is overturned.

This young child had a diagnosis of autism spectrum disorder. He had deficits in nonverbal communication, had restricted repetitive stereotypic behaviors, had deficits in social emotional reciprocity, difficulties interacting with peers and playing cooperatively, had difficulty with self-regulation, had maladaptive behaviors including aggression physically and tantrums, lacked functional skills, had an inability to play age appropriately with toys, had deficits initiating and maintaining relationships, did not share toys or take turns, was inflexible in routines, made nonsensical babbling and sounds, had difficulty sustaining shared attention, had low frustration tolerance, had impaired verbal communication, had echolalia, difficulties transitioning, had sensory seeking behaviors, and did not communicate when soiled or wet. He also reportedly had clinically significant impairment in social and other important areas of functioning. The recommendation was for applied behavior analysis (ABA).

The medical records provided enough specific evidence to support that he required applied behavioral analysis (ABA) therapy due to his severe developmental delays and autism spectrum disorder diagnosis. 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.

Multiple sources support that applied behavioral analysis is an appropriate and effective treatment behaviorally and educationally for autistic spectrum disorder individuals with social delays, language and communication delays, and difficulties in adaptive functioning. In this case this patient reportedly had developmental delays in social interaction and communication, deficits in social and emotional reciprocity, delayed language, social interaction, deficits in nonverbal communication, had restricted repetitive stereotypic behaviors, had deficits in social emotional reciprocity, difficulties interacting with peers and playing cooperatively, had difficulty with self-regulation, had maladaptive behaviors including aggression physically and tantrums, lacked functional skills, had an inability to play age appropriately with toys, had deficits initiating and maintaining relationships, did not share toys or take turns, was inflexible in routines, made nonsensical babbling and sounds, had difficulty sustaining shared attention, had low frustration tolerance, had impaired verbal communication, had echolalia, difficulties transitioning, had sensory seeking behaviors, and did not communicate when soiled or wet. He also reportedly had clinically significant impairment in social and other important areas of functioning.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for applied behavior analysis (ABA) assessment (97151, 12 units) is substantiated.