colorado family wins insurance for

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;