Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a nine-year-old female with a history of autism spectrum disorder and a speech 
delay. The patients parent has requested reimbursement for the ABA services provided from 
12/1/21 through 5/13/22. The Health Insurer has denied the services at issue as not medically 
necessary for the treatment of the patient. Therefore, the Health Insurer has denied coverage for 
the services at issue. This denial is the subject of this appeal and determination. The physician 
reviewer found that Papatola and Lustig described the features that must be considered in order to 
evaluate for medical necessity to be met for ABA services. Per these guidelines, a medical 
diagnosis of autism using standardized measures such as the Autism Diagnostic Observation 
Schedule, Second Edition (ADOS-2) and evidence that the symptoms of the disorder are causing 
impairment. In this case, the patient was assessed at 2.5 years of age using standardized measures. 
The result of this assessment was a diagnosis of autism spectrum disorder. There is evidence in 
the records that the patient was seen for re-evaluation. The assessment appeared to involve a record 
review, the patients history with limited direct evaluation, and no standardized assessments. The 
outcome of this assessment was that the provider recommended continuation of ABA and gave a 
diagnosis  of  attention-deficit/hyperactivity  disorder  (ADHD),  inattentive  type,  and  mixed 
expressive-receptive language disorder. Given the lack of standardized assessment, these findings 
should not be considered a replacement for the patients autism spectrum disorder diagnosis since 
autism spectrum disorder and neurodevelopmental disorders are listed as active diagnoses along 
with ADHD and mixed expressive-receptive language disorder in the records. In addition, the 
CARD providers included an initial assessment and progress reports for numerous dates from 2017 
through 2021 documenting the patients current functioning using standardized measures which 
resulted  in  evidence-based  treatment  recommendations  with  measurable  outcomes.  Each 
assessment contained standardized measures and reported measurable outcomes on treatment 
goals which developed based on a comprehensive history and assessment of the patients skills 
and interfering behaviors. Moreover, the services were provided in the least restrictive setting 
possible and were required for purposes other than convenience. Furthermore, the patients 
progress  reports  submitted  by  CARD  demonstrated  a  measurable  reduction  in  challenging 
behaviors and an increase in independent functioning over time. The provider monitored the 
maintenance and generalization of the patients reduction in challenging behaviors across settings, 
staff, and more natural behavioral contingencies. Overall, the provider delivered the ABA therapy 
in accordance with generally accepted practices and met the definition of medically necessary 
ABA services from Papatola and Lustig. Finally, the ABA services provided from 12/1/21 through 
5/13/22 were medically necessary per the Council of Autism Service Providers (CASP) practice 
guidelines. An objective assessment and analysis of the patients condition by observing how the 
environment affects the patients behavior, as evidenced through appropriate data collection was 
included for review. Per the CARD reports, the patients ABA provider submitted an initial 
assessment and progress reports dated from 2017 through 2021. Each assessment contained 
standardized measures including the Vineland Adaptive Behavior Scales and reported measurable 
outcomes on treatment goals. In this patients case, the appropriate context for the treatment of 
two goals was low preference activities. These goals included sustaining attention for non-
preferred activities and non-social flexibility in the form of remaining calm when asked to stop or 
prevented from engaging in expected preferred activities. While the clinical notes reference the 
completion of homework on a couple of occasions, this information is to provide additional 
information on the context of goal implementation and does not indicate intervention for goals that 
are not identified in the treatment plan. The records do not suggest that the patient has significant  cognitive impairment. The diagnostic report at age 2.5 indicates that the patient did not meet the 
criteria for intellectual disability and further stated that although the patients scores on the Mullen 
indicated a possibility of intellectual disability, given her young age and behavioral presentation 
the evaluator was not able to evaluate her true abilities. The provider utilized the principles and 
procedures of ABA such that the patients health, independence, and quality of life were improved. 
On review of the records, the information presented in the progress report indicates steady progress 
on both skill acquisition treatment goals and decreases in challenging behavior. In terms of 
challenging behaviors, the provider systematically worked to create a behavior plan to reduce 
challenging behaviors including tantrums, aggression, and noncompliance. The provider also 
ensured that the patients behavior plan could be faded to more natural contingencies while 
maintaining low levels of challenging behaviors across settings and people. Per the behavior plan, 
working on non-preferred tasks for at least 15 minutes before accessing preferred activities was 
one way to ensure that there were ample opportunities to ensure that the reduction of challenging 
behaviors was maintained and generalized. The progress reports indicate ongoing modifications 
to the treatment plan and behavior intervention plan based on data resulting from the patients 
progress. In conclusion, given that the services rendered met both the medical necessity criteria 
outlined by Papatola and Lustig and the core characteristics of ABA outlined by CASP, the ABA 
treatment provided from 12/1/21 through 5/13/22 was medically necessary for the treatment of the 
patients medical condition.