Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.

Treatment: 10 hours per week of applied behavioral analysis (ABA) therapy, and 1 hour per week of supervision.

The insurer denied coverage for 10 hours per week of applied behavioral analysis (ABA) therapy and 1 hour per week of supervision.

The denial is overturned.

This child reportedly has a diagnosis of Autism Spectrum Disorder and had deficits in social communication and social interaction, maladaptive behaviors, perseveration, a history of refusals, tantrums, physical aggression, self-harm behaviors, elopement, food shoving, and required prompting to attain tasks, identify emotions, maintain safety, navigate socialization with peers. The patient reportedly was receiving applied behavioral analysis therapy (ABA) for 6 years with reported progress especially with tantrums, elopement, physical aggression, self-harm behaviors, and refusals. The patient reportedly had been in a 12:1:1 restrictive classroom with speech therapy and occupational therapy services, and behavioral consultant. The patient reportedly lives with their mother and siblings. 

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 it was reported that the patient made progress but still was struggling in some areas and required continued ABA therapy. It was reported that the patient had developmental delays in social communication and social interaction still, needed verbal reminders and additional prompting to complete self-help skills on top of visual aids in place, needed monitoring for appropriate bites when eating, and that the patient was still scripting during activities of daily living (ADL's) such as showering which interfered with their ability to complete these tasks without prompting. The patient reportedly had verbal protests and negative statements in response to demands and nonpreferred tasks and it was at higher rates. It was reported that the patient still needed to be monitored for threats of aggression. It was reported that the patient was perseverating on where their mother and sister were which interfered with the patient's ability to focus on the task at hand. It was reported that the patient had inappropriate lifting of the shirt and was reported that community safety was still a concern. It was reported that the patient required moderate prompting to navigate socialization with peers, continued to display significant deficits in socialization, communication and ADL's, and still had vocal outbursts and disruptions. It was reported that the patient still needed to make more progress in order to try to achieve more independence and acquisition of skills, as well as better safety.  

Based on the above, the insurer's denial must be reversed. 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 10 hours per week of applied behavioral analysis (ABA) therapy, and 1 hour per week of supervision is substantiated.