Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Carnitine palmitoyl transferase 1A deficiency.
Treatment: Applied Behavior Analysis (ABA) Pre-service.

The insurer denied the Applied Behavior Analysis (ABA) Pre-service.  The denial is upheld.

The patient is a male born preterm who has carnitine palmitoyl transferase 1A
(CPT1A) deficiency, a rare genetic disorder of long-chain fatty acid oxidation.
The patient underwent psychoeducational testing at school. On the Preschool
Language Scale, Fifth Edition (PLS-5), one of the three standard scores was 66.
A PhD-level neuropsychologist evaluated the patient. On the Differential Ability
Scale, Second Edition (DAS-II), Verbal Reasoning was 66 and Nonverbal
Reasoning 87. The neuropsychologist also administered the Beery-Buktenica Test of Visual Motor Integration (Beery VMI), BASC (Behavior Assessment System for
Children), ABAS-3 (Adaptive Behavior Assessment System, Third Edition), and
WRAVMA (Wide Range Assessment of Visual Motor Abilities). The
neuropsychologist wrote a lengthy, verbose impression but failed to document a
specific medical diagnosis. She deferred diagnosing him with autism spectrum
disorder (ASD).

The patient's pediatrician wrote a medical statement indicating that he has "sensory
processing disorder."

A master's-level school psychologist evaluated the patient. On the Wechsler Scale
of Nonverbal Ability (WNV) the Full-Scale IQ (Intelligence Quotient) was 85; that score falls in the average range of 85 to 115. On the Vineland Adaptive Behavior Scale, Third Edition, the Adaptive Behavior Composite was 74. The school psychologist failed to
document a diagnosis or make any recommendations.

For undocumented reasons, the patient began participating in social skills group.

The patient underwent another psychoeducational evaluation, this time with
standardized achievement testing. Despite his largely average standard scores on
testing, he is in a full-time special education classroom that uses applied behavior
analysis (ABA) philosophy.

No, the health plan should not cover the ABA (applied behavior analysis) therapy.

ABA (applied behavior analysis) therapy is appropriate when a patient meets all the
following [Chiang, Murza, Pederson, Reichow, Volkmar]:

Proposed treatment is clinically appropriate as indicated by ALL the following:

Patient has a confirmed diagnosis of autism spectrum disorder (ASD) defined as
follows:

1) Evaluated by a qualified diagnostician, defined as any of the following (practicing
alone or as part of an interdisciplinary team):

a) Board-certified developmental-behavioral pediatrician, b) Board-certified neurodevelopmental pediatrician, c) Board-certified child neurologist, d) Doctoral-level clinical child psychologist (i.e., PsyD or PhD) [Met], e) Licensed school psychologist [Met], or f) Clinical child psychiatrist.

2) Diagnosis based on ALL the following:

a) Parent / caretaker interview [Met], b) Unstructured, informal clinical observation [Met], c) Semi-structured clinical observation using the Autism Diagnostic Observation, and d) Schedule-2nd Edition (ADOS-2) with a module appropriate to the child's language
level [Not met].

3) Patient meets DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth
edition) diagnostic criteria, which requires confirmation of both the following:

a) That global developmental delay or intellectual disability does not better explain the
patient's symptoms [Not met. This is not documented.], and b) That language delay or disorder does not better explain the patient's symptoms [Not met. This is not documented.].

4) Proposed treatment and monitoring plan is appropriate as indicated by ALL the
following:

a) A board-certified behavior analyst (BCBA) evaluated the patient using a clinical tool
specifically developed for serial evaluation of children with ASD (autism spectrum
disorder) and/or developmental disabilities (e.g., ABLLS-R [Assessment of Basic
Language and Learning Skills, Revised], AFLS [Assessment of Functional Living
Skills], ESDM [Early Start Denver Model], Essential for Living, PEAK-DT [Promoting
Emergence of Advanced Knowledge Direct Training], Skills for Autism, VB-MAPP
[Verbal Behavior Milestones Assessment and Placement Program]) rather than a
broad measure of adaptive skills (e.g., Vineland Adaptive Behavior Scales, 3rd
Edition [Vineland-3] or Adaptive Behavior Assessment System, 3rd Edition [ABAS3] or a screening tool based solely on parent interview (e.g., Behavior Language
Assessment Form [BLAF], Autism Treatment Evaluation Checklist [ATEC],
Questions About Behavioral Function (QABF), Social Skills Improvement System
Social-Emotional Learning Edition (SSIS-SEL)) [Not met. This is not documented.], b) Significant maladaptive behaviors or skills deficits are identified and within the
treatment domain of ABA (Applied Behavior Analysis)-based treatments (e.g., self injury, aggression, deficits in social-communication, restricted repetitive behaviors)
[Not met. This is not documented.], and c) Patient is expected to be able to adequately participate in treatment (e.g., sufficient language and intellectual capacities). [Met]

5) Treatment intensity (i.e., number of hours per week) and duration (i.e., length of
service intervention) is individualized and designed to meet needs of patient and
adjusted as is clinically appropriate; program selection impacts intensity and
duration, and may include 1 or more of the following:

a) Comprehensive ABA (Applied Behavior Analysis) for patients with ASD (autism
spectrum disorder) who are 18 months to 12 years of age and require program
designed to address multiple areas of behavioral and functional impairment in
coordinated manner [Not met. This is not documented.], or b) Treatment is to be administered in setting (e.g., home or specialized center) specifically designed and compatible with patient's needs and abilities [Met].

6) Treatment plan defines specific target behaviors and skills to be addressed, which
includes as a minimum the core features of ASD (autism spectrum disorder):

a) Social-communication deficits [Met], b) Restricted, repetitive behaviors [Met], c) Treatment plan includes explicit and measurable goals (e.g., behavior change, skill
development) that will define patient improvement (if present) [Not met. This is not
documented.], d) Treatment plan includes regular interval assessments of patient progress (or lack of progress) as measured by identified goals [Not met. This is not documented.], e) Treatment duration will depend on patient's ability to participate effectively, and attainment of specified goals [Met], and f) Treatment plan engages family, caregivers, and other people impacted by and in position to affect patient behavior, as appropriate. [Met]

7) Continued treatment is appropriate as indicated by ALL the following:

a) Functional progress has been made during initial therapy, as evidenced by a
significant improvement in performance on normed, referenced, or standardized
testing (e.g., ABLLS-R [Assessment of Basic Language and Learning Skills,
Revised], AFLS [Assessment of Functional Living Skills], ESDM [Early Start Denver
Model], Essential for Living, PEAK-DT [Promoting Emergence of Advanced
Knowledge Direct Training], Skills for Autism, VB-MAPP [Verbal Behavior
Milestones Assessment and Placement Program]) reported as objective increase in
standard score, developmental quotient, percentile, or percentage) [Not met. This
is not documented.], b) Generalization and carryover of targeted skills into natural environment is occurring [Not met. This is not documented.], c) Patient is actively participating in treatment sessions [Met.], and d) Caretakers are actively involved in teaching sessions [Not met. This is not documented.]

Frequency of therapy:

Guidelines and evidence reviews recommend at least 15 hours per week and no
more than 25 hours per week of ABA (Applied Behavior Analysis) therapy over 1 to
4 years, depending on a child's response to treatment [Chiang, Murza, Pederson,
Reichow, Volkmar]. Thus, the request for 40 hours of ABA (Applied Behavior
Analysis) therapy per week of direct 1:1 therapy is excessive.

In conclusion, the patient is not diagnosed with ASD (autism spectrum disorder).
Clinical records fail to document a rigorous comprehensive evaluation by a qualified
diagnostician (e.g., clinical child psychologist, child psychiatrist, board-certified child
neurologist, board-certified developmental-behavioral or neurodevelopmental
pediatrician) that includes administration of the Autism Diagnostic Observation
Schedule, Second Edition (ADOS-2); and review of the DSM-5 (Diagnostic and
Statistical Manual of Mental Disorders, fifth edition) diagnostic criteria. In the
absence of a substantiated diagnosis of ASD (autism spectrum disorder), applied
behavior analysis (ABA) therapy is not medically appropriate or standard of care.