Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism.
Treatment: Intensive Behavioral Therapies (IBT) - Applied Behavioral Analysis (ABA).

The insurer denied the Intensive Behavioral Therapies (IBT) - Applied Behavioral Analysis (ABA).  The denial is overturned .

This case involves an adolescent and emerging adult female with a longstanding diagnosis of autism spectrum disorder (ASD) and associated symptoms of behavioral and communication problems. Specifically, the patient has deficiencies in social functioning with communication skills with lack of spontaneity, problematic social skills and behavioral issues related to social, obsessive and generalized symptoms of anxiety including problems with empathy, eye contact, social interactions, self-management, coping skills, and safety concerns in her interactions with others (friends, acquaintances and strangers). The patient has received an assessment and recommendations for treatment with Applied Behavioral Analysis (ABA) therapy with respect to "exemplars" and treatment goals addressing the problematic behaviors identified.

A referral is in concert with the patient's clinicians and family with plan for Applied Behavioral Analysis (ABA) services to facilitate social skills and cognitive skills while transitioning to more independent functioning and decreasing or eliminating problematic behaviors. The assessment and development of a treatment plan generally includes plans for intensive behavioral treatment as follows: compliance training, distress tolerance using preferred and non-preferred activities, reinforcement applications, and caregiver training.

There are no issues in this case with psychosis, suicidality, thought disorder, or mania.

The treatment plan will incorporate/work on social skills deficits; communication deficits; and, behavioral issues in the context of continued work with the parents and/or supervision of caregivers. 

The health plan has denied the request for Applied Behavioral Services on the basis of the plan administrative policy for Behavioral Health Services and Autism Spectrum Disorder, and clinical criteria pertaining to Applied Behavioral Analysis for Autism Spectrum Disorder. The denial determination questions the diagnosis of autism and indicates that the evaluation did not utilize standard assessments.  The appeal is on the basis of the clinical features and diagnosis of autism spectrum disorder indicating that Applied Behavioral Analysis (ABA) is appropriate and in keeping with the assessment outlining the deficits and problematic behaviors to be addressed.

The Issue Under Review is Applied Behavioral Analysis (ABA).

Yes, the proposed treatment was medically necessary for this patient.

The requested Intensive Behavioral Therapies and mental health services are clinically appropriate, reasonable, likely to benefit the patient with regard to the diagnosis of Autism spectrum disorder, are evidence-based interventions to address behavioral disturbances and deficits, and are entirely consistent with prevailing standards of medical practice. 

The requested Intensive Behavioral Therapies per the treatment plan recommended are reasonable in this case scenario and are supported by the scientific literature with regard to treatment of patients with Autism spectrum disorder and associated behavioral disturbances known to occur in emerging adults and adolescents with autism spectrum disorder, especially at the time of transitioning to independent living in late adolescence. Thus, the intensity of behavioral therapies is reasonable and warranted in this case scenario. Additionally, employment of Applied Behavioral Analysis (ABA) services together with the other services being provided are in the best interest of this patient.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

In view of the problematic behaviors and impaired functioning, the assessment and requested Intensive Behavioral Therapies with Applied Behavioral Analysis (ABA) services are reasonable and medically necessary in this case. Moreover, a detailed treatment plan with target symptoms and behaviors is outlined by the assessment, is a reasonable next step in management of this patient's autism and comorbidities, is warranted and deemed to be medically necessary, and is the most likely active treatment to provide additional benefit to the patient in this case scenario.