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Action taken against Blue Shield of California for denying autism treatment coverage Posted: July 15th, 2011

By Maryalene LaPonsie

The California Department of Insurance (CDI) has issued an Order to Show Cause to Blue Shield of California after the health insurance company denied coverage for a specific autism treatment. The action comes as the result of the parents of two children contacting the CDI for an independent medical review (IMR) following a claim denial from Blue Shield of California.

At issue is Applied Behavioral Analysis (ABA) therapy, which uses behavioral conditioning techniques to teach autistic individuals new skills. According to the CDI, the therapy is a common and proven approach to address the symptoms of autism. In addition, the department says ABA is a medically necessary treatment and covered by California's Mental Health Parity Act.

Despite the findings of the IMR, which supported the use of ABA, Blue Shield of California continued to deny coverage saying the therapy is experimental and not actually a health care service. In addition, the health insurance company does not include ABA providers in its network.

In response to Blue Shield of California's refusal to adhere to the binding determinations of the IMR, the CDI issued a cease and desist order. Blue Shield of California has yet to issue a statement or response regarding the enforcement action.