ABA therapy was denied by insurance. How do I appeal?
An ABA denial usually turns on diagnosis, treatment plan specificity, provider credentials, hours requested, or whether the plan says the service is educational rather than medical. Appeal by matching the child's evaluation and treatment plan to the plan's ABA criteria, and ask for external review if medical necessity is upheld against you.
What to do, in order
- Step 1
Get the ABA policy
Ask for the plan's ABA or autism-services medical policy, including criteria for initial authorization, hours, supervision, and progress review.
- Step 2
Map the treatment plan to the criteria
The plan should see diagnosis, baseline behaviors, measurable goals, frequency and duration, BCBA supervision, parent training, and why a lower intensity would not work.
- Step 3
Answer the 'educational' argument
Show that the requested service treats functional impairments and medically necessary behavioral goals, not only school support. If an IEP exists, include it only to distinguish what school provides.
- Step 4
Use urgent or external review when needed
If a delay risks regression or harm, request expedited appeal. If the internal appeal is upheld on medical necessity, request external review.
The deadline that applies
Most employer and ACA plans give at least 180 days to appeal and must decide pre-service appeals within 30 days, 72 hours if urgent (29 CFR 2560.503-1; 45 CFR 147.136). State autism mandate rules may add rights for insured plans, but the plan letter controls the appeal date.
Calculate your date →Documents to gather
- The ABA denial and plan policy
- Diagnostic evaluation
- ABA treatment plan with measurable goals
- Provider credentials and supervision plan
- Records showing regression, safety risk, or failed lower intensity if relevant
Go deeper
Related questions
Can the plan deny ABA as educational?
It can try, but the appeal should separate school services from medically necessary behavioral treatment and show the clinical goals.
Do state autism mandates apply to every plan?
No. State mandates usually apply to insured plans, not self-funded employer plans. Check whether the plan is self-funded.
How many hours should the appeal request?
The number must come from the treating provider's plan and baseline data. The appeal should defend the requested hours against the plan's criteria.
Sources
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