Applied Behavioral Analysis denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a 5-year-old male enrollee has requested coverage for continuation of applied behavioral analysis therapy with an additional administer/coordinate therapies for treatment of the enrollee’s autism spectrum disorder. Findings: Three physician reviewers found that this case concerns a 5-year-old male with a diagnosis of pervasive developmental disorder (PDD). He was the product of a premature fraternal twin pregnancy and was delivered by Cesarean-section weighing 5 pounds 1 ounce, without neonatal difficulties. His early development was normal with walking at 1 year, first words at 1 ½ years, and phrases by 3 years. Despite this, his expressive speech developed poorly and the patient had nearly continuous tantrums and was readily frustrated. At the age of 3, he was placed in a school early intervention program.

The parent of a 2-year-old female enrollee requested (1) 30 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy; (2) 3 hours per week of ABA parent training; (3) 6 hours per week of ABA supervision; (4) 2 hours per week of occupational therapy; and (5) 2 hours per week of speech therapy for medical reatment of the enrollee’s autism spectrum disorder (ASD), developmental delay and developmental speech and language delay. Findings: The physician reviewer found that based on the documentation submitted for review, the request for 30 hours per week of direct one-on-one applied behavioral analysis (ABA) therapy, 3 hours per week of ABA parent training and 6 hours per week of ABA supervision is medically necessary for treatment of the patient’s ASD.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for an increase of four hours of applied behavioral analysis (eight hours total). Medical guidelines on Applied Behavioral Analysis treatment of autism spectrum disorder note that a developmentally appropriate applied behavioral analysis assessment process must identify strengths and weaknesses across domains and potential barriers to progress. The information from this process is the basis for developing the individualized applied behavioral analysis treatment plan.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. Findings: The physician reviewer found that based on the documentation submitted for review, the patient does not have a diagnosis of ASD. In 2010, 2013, and 2014, the patient did not meet criteria for ASD using the DSM-IV. In 2015, the diagnostic criteria changed to DSM-V. Based on DSM-V criteria many children with PDD, NOS diagnosis no longer meet the criteria for ASD. The documentation submitted for review describe difficulty with oppositional behavior, inattention and social difficulties. These symptoms are likely due to the patient’s learning disabilities that include her working memory and processing speed with particular difficulty in listening comprehension. She also has symptoms of ADHD.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Applied Behavioral Analysis, then check the rights and deadlines that apply to your plan.