The Department of Managed Health Care has declined five requests for independent medical reviews of insurers' denials for a type of autism treatment, sparking concerns from parents of children with autism and legislative leaders, the Los Angeles Daily Journal reports.
Insurers maintain that applied behavior analysis, also called ABA, is an educational treatment, not a medical service. Health plans have declined to cover the service, which can cost $70,000 annually.
Until recently, DMHC forwarded appeals of such claims denials to independent medical reviews, but the department has shifted the way it interprets state law.
According to the Daily Journal, the new interpretation means that regulators will reject requests for independent medical reviews if a health insurance policy does not guarantee coverage of the service.
DMHC spokesperson Lynne Randolph said the agency is reviewing each case individually and would grant independent medical reviews for appropriate cases.
Licensed Providers
Parents also are having problems getting health plans to cover ABA services because insurers are requiring a licensed provider to perform the service.
California currently does not require licenses for ABA providers, and parents of autistic children have reported obstacles obtaining lists of licensed ABA providers (George, Los Angeles Daily Journal, 5/11).