Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism spectrum disorder
Treatment: 16 hours/week of direct  Applied Behavioral Analysis (ABA) and 4 hours/week of group ABA
The insurer denied coverage for 16 hours/week of direct ABA and 4 hours/week of group ABA.
The denial is overturned.

 
This child has diagnosis of Autism Spectrum Disorder and developmental delays in social communication and social interaction. He reportedly had self-stimulatory behaviors, difficulty with attention, lacked motivation to follow instructions, noncompliance, dangerous behavior including elopement, and had deficits in communication, social skills, and adaptive functioning. The patient was receiving  Applied Behavioral Analysis (ABA) therapy for a few years with some reported improvements. The request was to continue ABA at the frequency of 16 hours/week of direct ABA and 4 hours/week of ABA group. 
  
The insurer denied the request to continue ABA at the requested frequency and approved 13 hours/week of direct ABA and 2 hours/week of ABA group, so they denied 3 hours/week of the additional direct ABA and 2 hours/week of the additional ABA group.
  
This reviewer disagrees with the decision to deny coverage for continued ABA at the frequency of 16 hours/week of direct ABA and 4 hours/week of ABA group as the medical records provided enough specific evidence to support that he still required this frequency of service. 

In this case this patient reportedly had developmental delays in social interaction and communication and deficits in adaptive functioning and was making progress with some goals but still needed the frequency of ABA therapy to sustain gains and make further improvements. Barriers to learning included that he still engaged in self-stimulatory behavior, lacked motivation to follow instructions or engage in presented activities, and not attending to presented task/activity materials, therapist's instructions, and had shortfalls in communication, social skills, and other adaptive functioning. The providers stated that he needed to continue at this frequency to sustain gains made on potentially dangerous maladaptive behavior such as elopement and for the importance of generalization of skills learned to overcome some of these maladaptive behaviors. Decreasing the frequency of this medically necessary intensive ABA therapy likely would result in loss of skills recently learned. Goals at the requested frequency that was denied by the insurer included: targeting problem behaviors such as self-stimulatory behaviors and noncompliance, dangerous behaviors such as elopement, better attending to present activities at task, being better able to request wanted items/activities, naming pictures with 2 components (of noun and verb), following instructions, selecting correct items from a book, sorting items from different categories, imitating verbal phrases, improving motivation and attention, communication, social skills, and adaptive functioning. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for 16 hours/week of direct ABA and 4 hours/week of group ABA is substantiated.