Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Carnitine palmitoyl transferase 1A deficiency.
Treatment: Applied Behavior Analysis (ABA) Pre-service.

The insurer denied the Applied Behavior Analysis (ABA) Pre-service.  The denial is upheld.

The patient is a male with a complex medical history, including carnitine
palmitoyltransferase, a disorder that prevents the body from using certain fats for
energy, particularly during periods without food such as fasting associated with
routine viral infections of which poor intake or vomiting occurs. In addition, the child
was a product of low birth weight and prematurity. He first participated in a
neuropsychological evaluation to assess multiple concerns including difficulties in
speech and language skills, motor, and behavioral functioning. The assessment
concluded that the patient was making overall appropriate developmental progress
but had concerning deficits in expressive language, and motor skills.
Recommendation included speech and occupational therapy.

A letter from the child's primary care provider refers to the patient's primary
diagnosis, carnitine palmitoyltransferase, and describes the disorder as often
accompanied by "flares" of behavioral changes/disorders. In this patient's scenario,
the symptoms are consistent with sensory integration disorder, and expressive
language deficits. The provider note adds that the patient has made great strides
socially and academically since starting ABA (applied behavior analysis) therapy.
The letter concludes that both the PCP (primary care provider) and behavioral
pediatrician support medical necessity for continued ABA (applied behavior
analysis) therapy.

The therapy has been denied coverage based on Plan policy that considers such
therapy as experimental/investigational for all diagnoses that are not within the
autistic spectrum and meet DSM-V (Diagnostic and Statistical Manual of Mental
Disorders, fifth edition) criteria.

No, the health plan should not cover the applied behavior analysis.

The health plan's denial of coverage is consistent with the current standard of care.
There is a growing list of disorders where the patient does not meet DSM-V
(Diagnostic and Statistical Manual of Mental Disorders, fifth edition) criteria for
autism and for which there is a dearth of well-controlled studies of significant
numbers that demonstrates efficacy of ABA (applied behavior analysis) therapy as
an approved treatment methodology. This would include this patient's primary
diagnosis of CPT-1 (Carnitine Palmitoyltransferase 1).

Other disorders that also have similarity to autism but that do not meet DSM
(Diagnostic and Statistical Manual of Mental Disorders) criteria may include
childhood disorder of social communication, or childhood disorder of social
functioning unspecified. Interventions for these conditions is often based on
principles of ABA (applied behavior analysis) therapy with modifications. However,
efficacy of ABA (applied behavior analysis) therapy for these and similar conditions
remains unproven to benefit management or health outcome.

Treatment with ABA (applied behavior analysis) is not an established standard of
care for these conditions, not supported as having proven efficacy, and is a nonautism clinical picture that is not meeting DSM-V (Diagnostic and Statistical Manual
of Mental Disorders, fifth edition) autism criteria.

No, the requested therapy is not established to be more beneficial for the enrollee
than any available standard therapy.

No studies with use of objective data have demonstrated that ABA (applied behavior analysis) therapy would be more beneficial than the previously recommended OT (occupational therapy) and speech therapy.