Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Applied behavioral analysis (ABA) services for autism spectrum disorder (ASD). 
The insurer denied coverage for applied behavioral analysis (ABA) services for autism spectrum disorder (ASD). 
The denial is overturned. 

This patient reportedly had a rare genetic disorder and had developmental delays, behavioral issues, and anxiety. The patient reportedly had chromosome 7q11.23 microduplication syndrome (William Beuren region duplication syndrome). The patient reportedly was receiving applied behavioral analysis (ABA) therapy and taking Aripiprazole, Fluoxetine, and Guanfacine. The patient reportedly had significant developmental delays, behavioral problems including physical aggression, anger outbursts, poor impulse control, and also had anxiety and attention problems. According to the medical records the note reported diagnoses of Attention Deficit Hyperactivity Disorder (ADHD), Unspecified Anxiety Disorder, Autism Spectrum Disorder with intellectual impairment associated with a known genetic condition (William Beuren region duplication syndrome), Childhood Onset Fluency Disorder, and Intellectual Disability-mild. It was reported that the patient was making progress with the treatment of ABA therapy and pharmacotherapy. 
  
The insurer denied coverage for applied behavioral analysis (ABA) therapy stating that this treatment is approved for patients with Autism Spectrum Disorder and that there was no documentation in the medical records of this diagnosis. 
  
This reviewer disagrees with the decision to deny coverage for applied behavioral analysis therapy as the medical records did provide enough specific evidence to support that she required this treatment. According to the note it was stated that discussion was made about having a formal diagnosis of Autism Spectrum Disorder which was greatly increased due to the patient's genetic condition and autism features and symptoms so Autism Spectrum Disorder with intellectual impairment associated with a known genetic condition (William Beuren region duplication syndrome) was documented in the notes. As a result, the applied behavioral analysis therapy is considered medically necessary treatment for this patient. According to the American Academy of Child and Adolescent Psychiatry applied behavioral analysis therapy is an effective behavioral treatment for autism spectrum disorder children, adolescents, and adults and has been shown to significantly facilitate acquisition of language, social skills, and improve behavior through early and sustained intervention. 

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  applied behavioral analysis is considered medically necessary treatment. This patient had deficits still developmentally and behavioral, ADHD, and anxiety symptoms still that required the treatment of applied behavioral analysis therapy treatment. As a result, the recommendation is to reverse the previous decision and approve coverage for ABA, applied behavioral analysis therapy, for this patient. It did not appear that the health care plan acted reasonably or in the best interests of the patient then. 

Based on the above, the insurer's denial must be upheld. 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 behavioral analysis (ABA) services for autism spectrum disorder (ASD) is substantiated.