Blue Cross Blue Shield of Michigan was “arbitrary and capricious” in denying reimbursement to a class of insured families for an aggressive form of autism therapy, on the grounds that it was “experimental or investigative,” a federal court judge ruled over the weekend.
U.S. District Judge Stephen Murphy in a 22-page written ruling ordered that all denied claims for coverage by insured people who obtained applied behavioral analysis therapy for children with autism spectrum disorder be sent back to the insurer, for “readministration.”
Murphy found in the class action lawsuit that Blue Cross could not support its conclusion in a 2010 medical policy statement that the effectiveness of ABA therapy “has not been established,” citing several studies that “almost universally conclude” that it has been.
“Remand (for readministration) is not an opportunity for (the Blues) to invent new bases for denial of claims that were not previously asserted,” Mruphy’s ruling states. “(And any) vague language denying a claim such as, ‘the service isn’t payable under your contract,’ shall (also) be construed as a denial based solely on the experimental/investigative exclusion, and the claim will therefore merit reimbursement.”The Detroit News reports:
Michigan's Medicaid and MIChild programs will cover the cost of applied behavior analysis services to treat young children with autism starting today.
The Michigan Department of Community Health recently received federal approval to provide applied behavior analysis services for children from 18 months through five years who have been diagnosed with autistic spectrum disorder, Asperger's disorder or pervasive developmental disorder-not otherwise specified.