Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: Applied behavioral analysis treatment

The insurer denied coverage for applied behavioral analysis treatment.

The denial is overturned. 

This male patient has a history of Down Syndrome and Autism Spectrum Disorder (ASD).

The National Institute of Mental Health reports that applied behavioral analysis 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 applied behavioral analysis 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 applied behavioral analysis is an appropriate and effective treatment behaviorally and educationally for autistic spectrum disorder individuals with social delays, language and communication delays, and difficulties in adaptive functioning. In this case this individual had significant deficits in language, social communication and interaction, daily living skills, and adaptive functioning and reportedly had a diagnosis of Autism Spectrum Disorder and Down's Syndrome and the recommended treatment was this treatment. The patient had a diagnosis of Autism Spectrum Disorder after being evaluated by a medical doctor who diagnosed this. He also reportedly had goals and objectives and multidisciplinary collaboration. It was reported that he required high rates of consistency in learning and applying new skills as well as skills for the caregiver. Other goals included to address poor social communication skills, social awareness, his lack of social boundaries and coping skills, modify rigidity, address social communication deficits, address physical and sensory deficits. Specific objectives included to answer who, when, why questions, determine when to be first, respond with giving an address, follow rules, share attention, greet familiar people, reinforce positive behaviors and extinguish negative behaviors, and improve motor planning.  Also, it was reported that the multidisciplinary services including medical, vision, hearing, genetic, developmental and behavioral coordinators and appropriate health care providers did have appropriate collaboration for the treatment of this patient. He required applied behavioral analysis services (ABA) including 2 hours per week of treatment planning, 2 hours per week of supervision/directions, 1 hour per week of board certified behavioral analysis family training, 15 hours per week of direct care by paraprofessionals, 5 hours of post assessment to further progress in the above mentioned areas and functioning as he had significant deficits and delays. Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder so treatment is complex and (ABA) applied behavioral analysis is considered medically necessary treatment.  He reportedly made some progress and was expected to make further progress with the continued applied behavioral analysis (ABA) therapy at the requested frequency and levels of care. The medical records provided enough specific evidence to support that he required this level of care.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for applied behavioral analysis treatment is overturned.  The medical necessity is substantiated.