Colorado Family Wins Insurance for Autism Services

An arbitrator in a Colorado family's dispute over whether Applied Behavior Analysis (ABA) therapy is covered under a health insurance plan has ruled in favor of the family seeking reimbursement for about $110,000 over two years of therapy.

Autism services advocates are hailing the decision in the case of Jill and Stephen Tappert who appealed several coverage denials for ABA services for their young daughter Abby by Anthem Blue Cross Blue Shield of Denver, as an important victory.

But a spokeswoman for Anthem told Denver ABC TV affiliate KMGH Channel 7 the insurance company believed Tappert case was a single instance and was not precedent-setting: "This decision is not a broad-based declaration that ABA therapy is 'medically necessary' in all cases. To what extent this type of therapy should be covered...should be made by legislators and/or the division of insurance."

It's not surprising for the insurer to assert a narrow reading of the case. However, families around the country could study the arbitrator's decision which clearly states that ABA is a mainstream, research-based approach for early intervention services for young children with an autism spectrum disorder diagnosis—and rejecting the insurer's arguments that it's not an effective medical treatment.

The case also raises questions for other insurance companies and whether they could use this decision to revise their coverage policies or the administrative rules that govern them.

One thing the Anthem spokeswoman hit upon was a legislative trend. The question about health insurance coverage for autism services such as ABA has, in fact, been a theme of legislative debates around the country as the issue makes its way through state-level debates. Reading different bills, some legislators leave the wording vague as to what health insurers should cover; new laws have passed in South Carolina, which calls for coverage of behavioral therapy, and Texas which calls for coverage of ABA. (Insurance industry and business industry lobbyists, meanwhile, have argued against any additional coverage because of the cost, in states like Pennsylvania.)

The Arbitrator's Findings

The arbitrator's decision document (dated Nov. 20 and issued by Judicial Arbiter Group) which Autism Bulletin received from advocates, provides a window into the health insurance company's policy on autism coverage. Anthem rejected coverage on the grounds that ABA services were not provided in a doctor's office, that ABA was not a medically valid treatment.

Some of Anthem's testimony appears to have been undercut by the fact that administrators and doctors with no experience treating autism cases were making decisions about whether ABA should be covered. Even so, the arbitrator's decision rejects Anthem's arguments and cites the testimony of Philip Strain, an early intervention autism expert and professor of educational psychology at University of Colorado at Denver states:

In his criticism of the Anthem policy, Dr. Strain points out that Anthem erroneously equates ABA therapy with Lovaas therapy—an approach which has received considerable justifiable scientific criticism. ABA therapy is based upon incidental teaching and pivotal response training, which Dr. Strain testified is the standard of care when dealing with autistic children.

According to Dr. Strain, instead of being investigational and experimental, ABA therapy reduces problem behaviors 80 to 90 percent and studies have replicated these results repeatedly.

Finally, Dr. Strain testified that the ABA therapy received by Abby was endorsed by the National Academy of Sciences—the recognized authority in the United States for resolving scientific disputes. Dr. Strain's opinions were echoed b Dr. Huckabee, Abby's treater for autism. Both Dr. Strain's and Huckabee's opinions are supported by the National Institute of Mental Health's publication on Autism Spectrum Disorders: "Among the many methods available for treatment and education of people with autism, applied behavior analysis (ABA) has become widely accepted as an effective treatment. Mental Health: A Report of the Surgeon General states: 'Thirty years of research demonstrated the efficiency of applied behavior methods in reducing inappropriate behavior and increasing social behavior.'"

Remember the American Academy of Pediatrics

The arbitrator's decision in this Colorado also case points out the importance of the recently launched autism awareness campaign at the American Academy of Pediatrics. The full-on effort to educate pediatricians about autism and early interventions to address the condition is likely to lead to more medical prescriptions for therapies such as ABA for young children who are diagnosed with autism spectrum disorders. It will also make it more difficult for health insurers to pledge ignorance about the legitimacy of such approaches.

Also see in the Autism Bulletin archives:

American Pediatricians Make Big Push for Autism Diagnosis, Awareness; Kits for Doctors, Checklists for Parents