Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for Applied Behavior Analysis (ABA) therapy. The patient is a nine-year-old male currently diagnosed with absent corpus callosum, Dandy-Walker malformation, developmental delay, epilepsy, and developmental speech and language disorder. Neurology evaluation indicates delayed milestones, with his receptive skill at around 80%. He displayed difficulty with non-verbal expressions, rigid thinking patterns, fixated interests and hyper/hyposensitive reactions to stimuli. The physician noted these were all characteristics of developmental delay and not autism spectrum disorder (ASD). However, the patient started applied behavior analysis (ABA) therapy. The record indicates he still did not meet ASD criteria, but had delayed social skills and repetitive behavior. He received physical therapy (PT), occupational therapy (OT), speech therapy (ST) and vision therapy once a week. An ABA report indicates the progress the patient was making with his current regimen and recommended an increase in treatment; from six hours per week to ten hours per week, with six hours of supervision per month for the next six months. He currently utilizes OT, PT, ST, adaptive physical education (PE) and a one-to-one aide. He attends a regular school with an individualized education program. The medical literature indicates applied behavior analysis (ABA) therapy is a behavioral intervention used to treat autism spectrum disorders in which the patients progress is tracked and measured.  Such therapy emphasizes communication, play, academic, social, work, community, and self-care.  ABA has been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD.  Literature support for applied behavior analysis is limited to patients with autistic spectrum disorder. The program is specifically designed to address the needs of patients with ASD. Based on literature review and DSM criteria, ASD is distinctively different from developmental delay. His physician applied the DSM criteria measures to appropriately rule out the diagnosis of ASD for this patient. While a suspicion for ASD is noted for the patients behavioral and social delay, neither the doctor nor the regional center has provided a follow-up DSM evaluation to support a definitive diagnosis of ASD for this patient. Rather, the physician considered the patients behavior was also related to attention deficit hyperactive disorder (ADHD) symptoms, and is treating the patient for ADHD. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child & adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.