Diagnosis: Autism Spectrum Disorder. Treatment: Autism Related Treatment. The insurer denied applied behavior analysis. The health plan's decision is overturned. The patient is a male who has Down syndrome. He underwent surgery for congenital heart disease early in life. He has been diagnosed with autism spectrum disorder by his pediatrician, and also on the basis of two psychological evaluations. This initial evaluation did not acknowledge the patient's diagnosis of Down syndrome. Limited information was provided regarding the patient's early medical and developmental history. He came into the care of his current foster parents at an early age. He received Early Intervention from that time, together with physical, occupational and speech therapy for 45-minute sessions twice weekly. After aging out of the early intervention program, he attended an Applied Behavior Analysis (ABA) class at a local public school, with an after-school respite program. He is now in a self-contained classroom with 7 students, 1 teacher and 6 aides at a private school for children with developmental disabilities. A report by his ABA therapy provider describes that he has been receiving ABA therapy with his current provider. He has been recommended to continue to receive 15 hours per week across 5 days at his after-school program and at home. The patient has significant delays in language and communication. He has made progress with manding for desired items but needs prompts to use full sentences. He has difficulty with behavior regulation and may tantrum if his wants and needs are not met. He struggles with lack of focus, having difficulty completing tasks. His sense of safety is poor, and he tends to elope in the community. He is making progress with socialization, for example sharing toys and exhibiting pretend play, but has difficulty advocating for himself, staying on task, and making appropriate comments to adults. A psychology evaluation included formal neuropsychological testing. The patient's first language was Yiddish. On the Comprehensive Test of Nonverbal Intelligence 2nd Edition (CTONI-2) his Full-Scale Nonverbal intelligence quotient (IQ) was estimated to be 58, in the mildly intellectually disabled range. On the Weschler Intelligence Scales for Children -5th Edition (WISC-V) his nonverbal IQ was estimated at 45. On the Gilliam Autism Rating Scale 3rd Edition (GARS-3) his Autism Index was 111, indicating that a diagnosis of autism spectrum disorder was very likely. At issue in this review is whether ABA therapy is medically necessary for this patient. The health plan's determination is overturned. The requested health service/treatment of Applied Behavior Analysis is medically necessary for this patient, to address his autistic features, including difficulty with social interaction, delayed language and communication, and safety issues including a tendency to elope when in the community.

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