Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder (ASD).
Treatment: Applied behavior analysis (ABA) behavior assessment (97151 12 units).
The insurer denied coverage for applied behavior analysis (ABA) behavior assessment (97151 12 units).
The denial is overturned.
 
This child has a diagnosis of autism spectrum disorder. He was observed to have deficits in communication, had restricted repetitive stereotypic behaviors, had deficits in social emotional reciprocity, limited interests with peers, was socially isolated, would not interact or respond to interactions, had poor eye contact and facial expression, could not comprehend nonverbal social communication, struggled with basic functional play, was not sharing with others, had severe impairment in verbal communication, difficulties with self-regulation, was having tantrums, property destruction, insisted on sameness, was perseverating, inflexible in routines, had difficulty sustaining shared attention, had low frustration tolerance, and had clinically significant impairment in social and other important areas of functioning. He has a diagnosis of Autism Spectrum Disorder. The recommendation was for applied behavioral analysis (ABA) therapy.
 
The insurer denied coverage for ABA, applied behavioral analysis therapy, for code 97151, stating that it was not medically necessary treatment. They stated that there was not a comprehensive evaluation submitted.
  
The medical records provided enough specific evidence to support that he required applied behavioral analysis (ABA) therapy, due to his severe developmental delays and autism spectrum disorder diagnosis. Applied Behavioral Analysis according to the American Academy of Child and Adolescent Psychiatry is an effective behavioral treatment for children with autism spectrum disorder 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 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 patient had developmental delays in social interaction and communication, deficits in social and emotional reciprocity, limited interests with peers, was socially isolated, would not interact or respond to interactions, had poor eye contact and facial expression, could not comprehend nonverbal social communication, struggled with basic functional play, was not sharing with others, had severe impairment in verbal communication, difficulties with self-regulation, was having tantrums, property destruction, insisted on sameness, was perseverating, inflexible in routines, had difficulty sustaining shared attention, had low frustration tolerance, and had clinically significant impairment in social and other important areas of functioning. He did have a comprehensive evaluation performed.

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

The medical necessity for applied behavior analysis (ABA) behavior assessment (97151 12 units) is substantiated.