Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder.

Treatment: 27 hours per week of 97153 (adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified health care professional, face-to-face with one patient), 2.5 hours per week of 97155 (adaptive behavior treatment with protocol modification, administered by a physician or other qualified health care professional, which may include simultaneous direction of a technician) and 1 hour per week of H0032 (mental health service plan development by a non-physician).

The insurer denied coverage for 27 hours per week of 97153, 2.5 hours per week of 97155 and 1 hour per week of H0032. 

The denial is overturned.

This patient reportedly had developmental delays in social communication and interaction and had a diagnosis of autism spectrum disorder. She reportedly had difficulty in social functioning, behavioral regulation, had restricted and repetitive eating habits, rigid thinking, difficulty reading peer's body language, voice tones, and facial expression, had difficulty in noisy environments, had difficulty tolerating varieties of food, and reportedly had a diagnosis of autism spectrum disorder. She reportedly had been in a self-contained classroom and had early intervention in the past. She reportedly was receiving applied behavioral analysis (ABA) services and made some gains. 

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. In this case this patient reportedly had developmental delays in social interaction and communication, limited range of interest, rigid thinking, repetitive behavior, social and communication deficits and had a diagnosis of autism spectrum disorder. The requested frequency and intensity of applied behavioral analysis treatment (ABA) services at 27 hours per week of direct care (97153), 2.5 hours per week of adaptive behavioral treatment modification (97155), and 1.5 hours of family adaptive behavioral treatment (97156) was considered medically necessary treatment and less services would likely have resulted in more regression and worsened functioning. Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder, so treatment is complex and (ABA) applied behavioral analysis is considered medically necessary treatment. As a result, the recommendation is to reverse the previous decision and approve coverage.

The insurer's denial of coverage for 27 hours per week of 97153 (adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified health care professional, face-to-face with one patient), 2.5 hours per week of 97155 (adaptive behavior treatment with protocol modification, administered by a physician or other qualified health care professional, which may include simultaneous direction of technician) and 1 hour per week of H0032 (mental health service plan development by non-physician) is overturned. Medical Necessity is substantiated.