Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Additional 8 hours a week of direct ABA (Applied Behavioral Analysis) therapy, 2 hours a week of supervision and 5 hours of reassessment. 

The insurer denied: Additional 8 hours a week of direct ABA (Applied Behavioral Analysis) therapy, 2 hours a week of supervision and 5 hours of reassessment. 
The denial is overturned. 

The patient is a preschool aged male child with a diagnosis of autism for whom an additional 8 hours per week of direct applied behavior analysis (ABA), 2 hours per week of supervision, and 5 hours or reassessment have been requested. The patient is currently receiving 9 direct applied behavior analysis hours in the school setting per week, 2.5 hours of speech therapy per week, 1.5 hours of physical therapy per week, and 1.5 hours of occupational therapy per week. According to a letter from the family, the child is only receiving 9 hours of direct applied behavior analysis in the school setting because the therapist is not available to provide the remaining 3 hours. He is receiving this one to one (1:1) support during the afterschool program. As a result of this support, the patient is demonstrating some improvement in eye contact, social overtures, self-soothing skills, and use of strategies to request items. According to his therapist, the patient more recently has been engaging in self-injury, aggression, and pica-like behaviors. He will bang his head on the floor and try to head butt others when frustrated or experiencing discomfort, when he is unable to communicate wants and needs. He is putting small objects in his mouth, increasing risk of aspiration and ingestion. The therapist is available to support and skillfully redirect him to safety. He exhibits similar behaviors at home, hitting himself in the head with fists, banging his head, hard enough to create bruising. He mouths environmental objects, eating them as well. When in the community, he is a significant elopement risk. At home and in the community, the child and family do not have the support of the therapist to redirect the child and teach the family effective strategies to intervene. 

The health plan has denied as not being medically necessary, stating that the previously authorized services (12 hours per week of direct applied behavior analysis therapy, 2 hours per week of supervision, 1 hour per week of parent training, and 3 hours of reassessment) are sufficient. 

The proposed additional therapy hours are medically necessary and appropriate for this child. 

Applied behavior analysis is a behavioral approach with a longstanding history of application with children on the autistic spectrum. The literature supports the utility of this method of intensive intervention particularly for autistic children with behavioral issues. Applied behavior analysis has been successfully used for decades across all environments (home, school, community) to increase communication, reduce problematic behaviors, and reinforce appropriate behaviors. 

This young child has multiple concerning maladaptive behaviors because of his autism, including self-injury (head banging, hitting himself in the head with knuckles), pica-like behaviors, aggressive behaviors (head butting others when frustrated or uncomfortable), and elopement behaviors when in the community. He is at great risk of traumatic brain injury, aspiration, poisoning, and trauma due to these behaviors along with profound lack of safety awareness. To have its best effects, applied behavior analysis is applied across all areas of functioning, including home, school, and the community. This child is not receiving adequate support, and as a result is exhibiting more concerning behaviors and engaging in more self-harm. The requested services (8 hours per week direct applied behavior analysis, 2 hours per week supervision, and 5 hours reassessment) are medically necessary and appropriate, consistent with standard of care and this patient's degree of disability.