Asperger Syndrome: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospitalization services. Findings: The physician reviewer found that due to the persistent affective symptom complex with disordered thought processing and violent behavior in context of autism spectrum disorder, a conservative psychiatric hospital stay was to be expected. Thus, the inpatient services provided in this case were reasonably expected to improve the patient’s condition and prevent a more serious episode of illness. Bipolar disorder is a chronic and debilitating mental illness. It is associated with poor clinical outcomes and erratic behaviors. The patient had been on a downward trend since late 2015. He was hospitalized earlier in 2016 and was not responding to outpatient treatment services. Upon presentation, the patient was violent, delusional and hypomanic.

A 25-year-old female enrollee has requested psychotherapy twice a week with a PhD psychologist, monthly psychiatric appointment with Comprehensive Neurobehavioral Specialists (CNS) and applied behavioral analysis (ABA) therapy for treatment of her mental health conditions. Findings: The physician reviewer found that applied behavior analysis (ABA) is an empirically proven treatment intervention for children, adolescents and adults afflicted with autistic spectrum disorders. However, the documentation provided does not substantiate a diagnosis of Asperger’s disorder. Determination of this condition involves input from multiple disciplines and structured interviews.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the central auditory processing disorder (CAPD) test for evaluation of his behavioral health condition. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. In general, central auditory processing refers to several systems involved in both verbal and nonverbal communication. Since there are multiple proposed mechanisms, the term central auditory processing disorder (CAPD) is rather non-specific with regard to etiology. There is a lack of adequately-powered, well-designed studies demonstrating the usefulness of testing.

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that on the date indicated, the patient’s psychotropic medication was increased. The patient had a good visit home around the holidays. Thereafter, he had a successful programming trip to a designated location. On the date indicated, his disrespectfulness responded well to redirection. On the date indicated, he “felt more confident” and more “empathetic” with an improved ability to consider the perspectives of others and “much greater control over his emotional state.” His previous episodes of acting out were limited to conflict with rules. However, he was responding to redirection. Moreover, there was no evidence of psychiatric instability or safety concerns.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for asperger syndrome was denied, the published record says the denial is worth fighting.