Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: Applied Behavior Analysis (ABA)

The insurer denied coverage for Applied Behavior Analysis (ABA.)

The denial is overturned.

This patient is a child who reportedly had a diagnosis of Autism Spectrum Disorder (ASD) and had developmental delays in social communication and social interaction. The patient reportedly had poor impulse control, behavioral issues including hitting others, throwing items, and touching others. The patient reportedly had struggles with attention to tasks. It was reported that the patient's mother stated that the slightest things trigger intense reactions and that the patient is unable to regulate themselves. The patient reportedly lived with their parents. It was reported that the patient received applied behavioral analysis (ABA) therapy to try to improve their functioning and behaviors and better foster independence.

The reviewer disagrees with the decision to deny coverage for applied behavioral analysis (ABA) therapy as the medical records did provide enough specific evidence to support that he required this treatment.  According to the American Academy of Child and Adolescent Psychiatry applied behavioral analysis (ABA) 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. 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 and adults with autism and other developmental disorder. 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. In this case it was reported that the patient had a diagnosis of Autism Spectrum Disorder and had deficits in social communication and interaction as well as behavioral issues including hitting others, throwing objects, and touching others, and had poor impulse control and difficulty regulating emotions. The patient reportedly had goals with ABA therapy to improve communication, socialization, emotional control and regulation, improve adaptive functioning, improve self-management, improve behavioral control, and foster skills acquisition as well as generalize learning to the untrained environment. The treatment also included reinforcements, shaping, prompting, behavioral skills training, self-management, and functional assessment. 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 and standard treatment for Autism Spectrum Disorder. This patient had deficits developmentally and behaviorally that required the treatment of applied behavioral analysis therapy (ABA) 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 reversed. 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 Behavior Analysis (ABA) is substantiated.