Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder

Treatment: Psychological Testing Evaluation Services

The insurer denied coverage for psychological testing evaluation services.

The denial is upheld. 

This patient is a male that reportedly had developmental delays and was in psychotherapy with his doctor with goals to improve coping skills, improve social and interpersonal skills, communication of thoughts and emotions, and decrease rigidity in thinking and used modalities of coping patterns, interactive feedback, interpersonal resolution, and supportive reflecting.  It was reported that the patient was diagnosed with Autism Spectrum Disorder and previously Asperger's Disorder.  It was reported that he was diagnosed by clinical intake, developmental history, Adult Asperger's Assessment Interview, ADOS-2 (Autism Diagnostic Observation Schedule, 2nd edition) module 4, rating scales-Autism Quotient, Empathy Quotient, and Social Responsiveness Scale. 

The decision to deny coverage for psychological testing is correct because there was no psychological testing evaluation detail in the medical records to review.  There also was no specific question to be answered for the psychological testing in the medical records provided for review.  

According to PubMed and the National Collaborating Center for Mental Health, "Autism: Recognition, Referral, Diagnosis, and Management of Adults with Autism Spectrum," under-recognition could lead to inadequate care, social and economic exclusions, masking of mental and physical health.  It also states that this is a diagnosis that can be diagnosed by clinical assessment but if possible quantifiable measures could also support it.  

According to the book Diagnosis and Assessment in Autism (2013) by Schopler and Mesibov, a diagnosis of mental impairment is one of the greatest sources of heterogeneity in autism so psychological testing could be considered helpful.  

The American Academy of Child and Adolescent Psychiatry Practice Parameters for the Evaluation and Treatment of Children, Adolescents, and Adults with Autism Spectrum Disorder reports that psychological testing can measure cognitive ability and adaptive skills indicated for further treatment planning, and clarify areas of strength and weakness useful in designing intervention programs.

Psychological testing is considered helpful in diagnosing Autism Spectrum Disorder and also in quantifying deficits in social communication and interaction as well as restricted repetitive and stereotypic behaviors, interests, or activities, as well as intellectual and adaptive functioning.  However, the medical records provided did not provide the psychological testing assessment information details or state specific questions to be answered by the psychological testing.  Most of the medical records were psychotherapy notes with goals to improve coping skills, improve social and interpersonal skills, communication of thoughts and emotions, and decrease rigidity in thinking and used modalities of coping patterns, interactive feedback, interpersonal resolution, and supportive reflecting.  Because the psychological testing was not available for review in the medical records provided, the denial is upheld and coverage is denied for psychological testing.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for psychological testing evaluation services is upheld.  Medical necessity is not substantiated.