Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
Treatment: Outpatient applied behavioral analysis (ABA) therapy care 
The insurer denied coverage for outpatient ABA therapy care. 
The denial is overturned.

This patient lives at home with their mother and father. The patient has a diagnosis of autism spectrum disorder and anxiety. The patient also has a long complex medical history and two genetical disorders, Wolf-Hirschorn Syndrome and Cockayne Syndrome, both of which have also affected her health and development. The patient was evaluated and Applied Behavioral Analysis (ABA) therapy was recommended but denied coverage by the insurance carrier due to not meeting medical necessity.

It is the reviewer's opinion that the health care plan should have allowed the patient to receive the recommend ABA therapy of 40 hours/week treatment. Notes provided clearly document severe deficits in behavior, communication and emotion dysregulation. Multiple providers have diagnosed this child with autism and noted the deficits socially, emotionally, behaviorally and deficits in communication. Multiple providers recommended ABA therapy. Given multiple providers documented the diagnosis of Autism, severe deficits and recommend ABA therapy, the best judgment of the health care plan would have been to cover the recommended services. 

In addition, ABA therapy is considered standard of care for children with Autism, regardless of their verbal skills. Long standing reputable organizations such as the American Academy of Child and Adolescent Psychiatry guidelines for the treatment of children of Autism clearly supports ABA treatment.  

The notes reviewed showed there was a clear documented clinical summary and treatment goals for all of the domains this patient struggles in. The clinical information clearly supports the need for intensive ABA therapy. Some examples are: the patient clearly struggled and many domains including, but not limited to following directions, engaging in conversation and also having aggressive behaviors toward self and others. The report reviewed also noted specific domains where patient struggled to achieve 25 percent (%) or less success and had a goal of 80% or more achievement. 
 
Some more examples of need for ABA therapy noted by the patient's providers were: the patient had deficits in appropriate play, turn taking skills, sharing, initiating conversating and perspective taking. Additional domains of 25% or less achievement were identifying emotions, facial expressions, social awareness, and greeting others. The patient was also noted to engage in self-injury behavior in a severe form. The patient was also engaging in aggressive behavior in the home. Elopement was also another behavior of concern. Given all these severe documented deficits, the patient could absolutely benefit from ABA therapy. Per records provided, there was clear documentation of behaviors needing to be addressed and plan to address this with ABA therapy, and goals met to meet needs.

The notes reviewed provided a clear clinical summary of an individual with the medical need for ABA therapy as evidenced by the patients struggles in multiple domains of behavior and communication. 

Autism is the primary diagnosis of this person and ABA therapy as one of the main standards of care for treatment with individuals with autism. Given the patient's very low adaptive skills, poor socialization, and communication and interpersonal skills, ABA therapy is medically necessary and will provide long lasting individual benefits as supported by research.

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

The medical necessity for outpatient ABA therapy care is substantiated.