Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder
Treatment: denied Additional 10 Hours a Week of Direct Applied Behavior Analysis (ABA) Therapy and 2 Hours a Week of Supervision
The insurer denied Additional 10 Hours a Week of Direct ABA Therapy and 2 Hours a Week of Supervision.
The health plan's determination is upheld.

The patient is a girl who has been diagnosed with autism spectrum disorder and attention deficit hyperactivity disorder. According to her applied behavioral analysis (ABA) report she also has "mild brain seizures." She was evaluated for early intervention services aged 2 1/2 years and was diagnosed with autism spectrum disorder based on parent interview and the Autism Diagnostic Observation Schedule (ADOS). From an early age, she had poor eye contact, lack of language acquisition, emotional disregulation, unresponsiveness and staring. Per the child neurologist's letter ABA therapy is needed to improve the patient's ability to function, and to address elopement risk and behaviors. The provider did not specify a specific number of ABA hours per week. Over the past year, she has been given trials of numerous psychotropic medications including guanfacine, divalproex, Depakote, clonazepam and Abilify.

Additional 10 Hours a Week of Direct Applied Behavior Analysis (ABA) Therapy and 2 Hours a Week of Supervision are not medically necessary for this patient.

In the most recent Guidelines on the Identification, Evaluation, and Management of Children With Autism Spectrum Disorder published by the American Academy of Pediatrics, Hyman et al report: "Most evidence-based treatment models are based on principles of ABA. ABA has been defined as 'the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior.' The use of ABA methods to treat symptoms of ASD suggests that behaviors exhibited can be altered by programmatically reinforcing skills related to communication and other skill acquisition. Thus, ABA treatments may target development of new skills (eg, social engagement) and/or minimize behaviors (eg, aggression) that may interfere with a child's progress." The American Academy of Pediatrics does not provide specific guidelines regarding number of hours of ABA therapy per week.

Orinstein et al reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes; the age at which ABA therapy was started and duration of treatment was correlated with outcome. Luiselli et al reached similar conclusions.

Tiura et al performed a study involving 35 children with autism spectrum disorder, average age 3 years, to determine predictors of benefit from ABA therapy. Using a growth curve analysis, they investigated if age, diagnosis severity, cognitive functioning, treatment hours, gender, parent education level, or primary language spoken at home significantly predicted the growth trajectories of ABA treatment outcomes. Using the Developmental Profiles-3rd Edition, they found that it indicated that higher cognitive functioning significantly predicted faster growth across all four developmental domains, age at entry predicted initial status, and other variables only predicted growth rates in one or two domains.