Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 

Treatment: Applied Behavior Analysis (ABA) services. 

The insurer denied coverage for ABA services. 

The denial is overturned. 

This is a female child who reportedly had developmental delays in social communication and social interaction and had a diagnosis of Autism Spectrum Disorder. She reportedly had poor communication skills and social skills when interacting with peers and adults making it difficult to sustain positive interactions independently. The patient also reportedly had weak cognitive and memory skills affecting her ability to comprehend and communicate within social situations and relationships. She also reportedly had attention and flexibility problems affecting her ability to sustain interactions and build positive relationships. The patient also had difficulty tolerating changes in routine, poor emotional regulation skills, lacked impulse control, and had difficulty following multi-step directions and expressing language. She reportedly had some progress when she had applied behavioral analysis (ABA) services though she still had significant deficits and required more treatment. The patient reportedly had gaps in ABA treatment due to coronavirus disease 2019 (COVID-19) and reportedly regressed. 

Applied Behavioral Analysis according to the American Academy of Child and Adolescent Psychiatry is an effective behavioral treatment for autism spectrum disorder children 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. 

The patient 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 these were considered core deficits to Autism Spectrum Disorder which needed to improve in order to improve her functioning. The patient reportedly regressed when she stopped these services due to COVID-19 and made some progress when she had these services though still had reports of significant delays and deficits. It was reported that she needed these services to improve more as she had current difficulty related to social and relationship deficits, developmental skills, communication skills, cognitive and attention skills, and daily living skills. She needed to make more progress also as she reportedly continued to display regulation and flexibility deficits and had made steady progress with these services in many target domains although she still lagged significantly beyond her age and peer group as these services were stopped during COVID-19.  

It did not appear that the insurer acted in the best interests of this patient.

The insurer's denial of coverage for ABA services is overturned. Medical necessity is substantiated.