Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autistic disorder.

Treatment: Applied Behavior Analysis (ABA) services.

The insurer denied coverage for applied Behavior Analysis (ABA) services.

The denial is overturned.

This patient reportedly had developmental delays in social interaction and communication, limited range of interest, rigid thinking, inflexibility in routines, rituals, repetitive behavior, social and communication deficits, marked deficits in verbal communication and interpersonal relationships, fixed interests, fixation with specific rituals, lack of engagement with peers or participation in groups, difficulty with conversation and social cues, maladaptive behaviors, withdrawn, resistant, high level of rigidity leading to meltdowns, strange and repetitive noises, and poor social and home functioning. He reportedly had a diagnosis of autism spectrum disorder. 
  
The medical records provided enough specific evidence to support that he required these services then. 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. 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. It was reported that according to the Autism Spectrum Quotient he scored a 42 and the cut off score for Autism is 32. Also, according to the Autism Diagnostic Interview-Revised the patient scored 28 for social interaction, 21 for communication/language, and 4 for restrictive and repetitive behaviors and the cut offs for Autism were 10, 8, and 3 so he met according to that as well. Goals for applied behavioral analysis (ABA) services included improving conversational skills, decreasing flexibility and rigidity, improving problem solving, increasing independence, improving social interactions and skills, decreasing rituals, challenging routines, and discrete trial learning and natural environment training net were used. The applied behavioral analysis (ABA) services included 5 hours of behavioral identification assessment, 13 hours per week of direct ABA therapy, 5 hours per week of group ABA therapy, 2 hours per week of supervision and treatment planning, 1 hour per week of parent training, and 3 hours per month of treatment planning. 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 (ABA) applied behavioral analysis is considered medically necessary treatment. As a result, the recommendation is to overturn the previous decision and approve coverage for applied behavioral analysis treatment (ABA) for this patient. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the Applied Behavior Analysis is overturned. Medical Necessity is substantiated.