Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
Treatment: Applied Behavior Analysis (ABA) Behavior Assessment (97151, 12 units)
The insurer denied coverage for ABA Behavior Assessment (97151, 12 units).
The denial is overturned.

The reviewer disagrees with the decision to deny coverage for applied behavioral analysis (ABA) therapy for code 97151 as the medical records provided enough specific evidence to support the required ABA therapy due to the severe developmental delays and autism spectrum disorder (ASD) diagnosis. ABA according to the American Academy of Child and Adolescent Psychiatry is an effective behavioral treatment for ASD 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 ABA is widely accepted as an effective treatment. The National Academy of Sciences reports that 40 years of research testifies to the efficacy of time limited focused ABA methods in reducing or limiting specific problem behaviors and teaching new skills to children and adolescents with autism and other developmental disorder. Multiple sources support that ABA is an appropriate and effective treatment behaviorally and educationally for ASD individuals with social delays, language and communication delays, and difficulties in adaptive functioning. 

In this case this patient has developmental delays in social interaction and communication, deficits in social and emotional reciprocity, delayed language, social interaction, maladaptive and stereotypic behaviors, difficulty interpreting social cues, could not sustain attention for more than 2 minutes, has social avoidance, maladaptive behaviors, aggressive behavior, tantrums, is not socially aware, is not picking up on verbal/nonverbal social cues, is acting inappropriately, cannot comprehend social norms, has rigid thinking, is making inappropriate comments, is struggling with perspective taking, cannot sustain conversation on topic and has difficulty with conversational skills, has poor emotional awareness, cannot self-regulate, is withdrawn socially, rambles and makes senseless speech, cannot understand nuances of language, is easily frustrated, has extensive latency, stereotypical behaviors, repetitive behaviors, and clinically significant impairment in social and other important areas of functioning. The child did have a comprehensive assessment done.

ASD is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder. Treatment is complex and ABA is considered a medically necessary treatment. Early intervention with ASD is important and has the best prognosis. This patient has significant deficits developmentally and requires the requested treatment of ABA, for code 97151. As a result, the recommendation is to overturn the previous decision and approve coverage for ABA for code 97151. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for ABA Behavior Assessment (97151, 12 units) is substantiated.