Autistic Disorders: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for weekly applied behavior analysis (ABA) services to include (per 6-month period): therapeutic behavioral services 390 hours, mental health service plan development by non-physician 82 hours, and mental health service plan development by non-physician 30 hours. Based on the medical records, the Model Policy Coverage from the ABA Coding Coalition, and the ABA Treatment Guidelines from the Council of Autism Service Providers (CASP), the requested services are indicated for this patient.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for all or any of the applied behavior analysis therapy services: therapeutic behavioral services total of 390 hours; mental health service plan development by non-physician 83 additional hours; home care training, family; and skills training and development total 39 hours, with the approved 10 hours of assessments. Per the medical records, the patient has a diagnosis of autism spectrum disorder.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for applied behavior analysis (ABA) services.Based on the information provided, the ABA Practice Guidelines from the Council of Autism Service Providers (CASP), the Model Policy Coverage from the ABA coding Coalition, and Papatola and Lustig's medical necessity criteria, the requested ABA services are not medically necessary for the treatment of this patient. The patient’s provider requested a comprehensive number of hours, but a limited number of goals were addressed in the treatment plan. Per the CASP guidelines, “Treatment intensity should reflect the complexity, breadth, and depth of treatment targets, as well as the environment, treatment protocols, and significance of patient needs.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for an increase of hours of applied behavior analysis (ABA) in-home therapy. Based on the provided medical records, the ABA Practice Guidelines from the Council of Autism Service Providers (CASP), the Model Policy Coverage from the ABA Coding Coalition, and the medical necessity criteria established by researchers, an increase in ABA therapy of additional hours of 1:1 therapy per week is not indicated for this patient. The requested increase of ABA therapy is not supported by any additional documentation. Therefore, the request does not meet several essential practice elements of ABA. Without data or goals, it is unclear how the additional hours per week will be utilized.

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 autistic disorders was denied, the published record says the denial is worth fighting.