Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: 30 hours/week of applied behavioral analysis (ABA) therapy, 6 hours/week of supervision, 2 hours/week of parent training, 1 hour/week of treatment planning, and 3 hours of reassessment

The insurer denied coverage for 30 hours/week of ABA therapy, 6 hours/week of supervision, 2 hours/week of parent training, 1 hour/week of treatment planning, and 3 hours of reassessment.

The denial is overturned.

This young adult male reportedly had a diagnosis of autism spectrum disorder and had significant developmental delays in social communication and interaction and language as he was nonverbal, had poor eye contact, repetitive and stereotypic behaviors, self-injurious and aggressive behavior, disruptive behavior, poor attention, significant deficits in functioning, and he requires supervision and prompting as he was considered a danger if not supervised and structured. He reportedly lived with his mother who was his legal guardian. It was reported that he received applied behavioral analysis (ABA) therapy for 5 years, but the insurer denied further coverage and it was reported that his functioning and symptoms worsened since then.

The medical records provided enough specific evidence to support that he required ABA therapy and this frequency and intensity of services due to his significant developmental delays and autism spectrum disorder diagnosis. ABA, according to the American Academy of Child and Adolescent Psychiatry, 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. The American Academy of Pediatrics reports that the efficacy of ABA 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 ABA 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 ABA methods in reducing or limiting specific problem behaviors and teaching new skills to children and adolescents and adults with autism and other developmental disorder. 

He reportedly was making slow progress and maintain gains when he had ABA therapy treatment. He was continuing to respond to interventions at a steady rate consistent with his ability to acquire and retain skills. He reportedly acquired and maintained many independent functional skills since ABA therapy treatment, which then worsened when it stopped. This also is specific evidence that he required continued ABA therapy. 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 is considered medically necessary treatment. 

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 30 hours/week of ABA therapy, 6 hours/week of supervision, 2 hours/week of parent training, 1 hour/week of treatment planning, and 3 hours of reassessment services is substantiated.