Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder 

Treatment: 10 hours of Applied Behavior Analysis (ABA). 

The insurer denied coverage for additional 10 hours of Applied Behavior Analysis (ABA). The denial is reversed. 

This patient is a male with impairment in social interaction and communication and had a diagnosis of Autism Spectrum Disorder.  He had aggressive and threatening, behaviors, property destruction, agitation, tantrums, yelling, stealing, lying, poor understanding of social expectations, cues and consequences to behaviors, and expression of emotions. He had late intervention, as he had Applied Behavioral Analysis (ABA) therapy since early-2019. He was attending private day school and had occupational and speech/language therapy. The insurer denied the additional 10 hours per week of ABA therapy, as they approved 25 hours per week of ABA therapy but approved only 15 hours per week thereafter.  They stated that the medical records did not provide enough specific evidence to support that frequency of services.

This reviewer disagrees with the decision to deny the additional 10 hours per week of ABA therapy and only approve 15 hours per week after mid-2019. as the chart notes did provide enough evidence to support that he still required 25 hours of ABA therapy.  This patient was in need of this frequency of services due to his developmental delays, maladaptive behaviors and functioning, and aggressive and threatening behavior. It was reported that he had severe deficits in communication and socialization domains, moderate deficits in safety and behavioral domains, mild impairment in self-care, and he had difficulty expressing emotions. Additionally, he had difficulties with social interaction, communication, and cues.  He did not receive early intervention and only started ABA therapy since early-2019; therefore, he required more frequent and intensive treatment to try and improve adaptive functioning, communication, and socialization, as well as improve behavioral control and decrease aggressive and maladaptive behaviors.  
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.  The NY State Department of Health recommends that applied behavioral analysis and behavioral intervention strategies be included as inpatient elements of any intervention program for autistic children.

As a result, reverse the previous decision and approve coverage for the previously denied additional 10 hours per week of ABA services for a total of 25 hours per week and not just 15 hours per week after mid-2019.  The health care plan did not act reasonably, or with sound medical judgment, of in the best interests of the patient.

The carrier's denial of coverage for additional 10 hours of Applied Behavior Analysis (ABA) is reversed.  The medical necessity is substantiated.