7th Circuit Rules on Covered Autism Therapies Under MPHAEA

Introduction 

In Midthun-Hensen on behalf of K.H. v. Grp. Health Coop. of S. Cent. Wisconsin, Inc.,  the Seventh Circuit upheld the district court’s grant of summary judgment1 to Defendant Group Health Cooperative in this lawsuit challenging the denial of speech therapy as a treatment for autism for a young child under the Mental Health Parity and Addiction Equity Act (MHPAEA). 

Bottom Line First 

It is crucial insurers have solid processes to comply with the MPHAEA when reviewing mental health therapy claims prior to denial. Human Resources professionals should fully understand the insurer’s claim review, the appellate process aligned with the insurer, and that those processes comply with the MPHAEA. 

For group health plan operational and administrative details, HR professionals should review their plan’s written plan document.  If the HR professional is unsure of what types of treatments are covered and why, they should seek additional information from the broker or the carrier. 

Evidence Based Treatments

The United States Court of Appeals for the Seventh Circuit reviewed the case and upheld the district court’s decision. The appellate court found that the insurer’s reliance on medical literature, which varied in its recommendations based on patient age, was permissible under the MPHAEA. The court also noted that the plaintiff failed to demonstrate that the insurer’s treatment limitations for mental health benefits were more restrictive than those applied to “substantially all” medical and surgical benefits, as required by the statute.  This is referred to as the “substantially all/predominant test” within the MPHAEA regulation. The court asserted no matter how much space “substantially” leaves, a showing that an insurer limits a mental-health benefit more than it does one medical benefit cannot show that it so limits substantially all such benefits.  

The court concluded plaintiffs did not seriously try to show that Group Health Cooperative, as a general matter, imposed age-based treatment limitations less stringently on medical (and surgical) benefits than on mental health benefits.  

The court asserted that the insurer is entitled to identify and rely on medical literature so long as its process for doing so applies to mental-health benefits and medical benefits alike. Limiting coverage to evidence-based treatments has the support of a regulation that plaintiffs do not contest.  

 Therefore, the court concluded that the plaintiffs’ focus on a single medical benefit (plaintiff’s focused on just the chiropractic benefit) was insufficient to prove a violation of the MPHAEA. 

Case Overview 

Plaintiffs sought coverage for specific therapies for their child, K.H., who was diagnosed with autism between 2017 and 2019. Their health insurer, Defendant Group Health Cooperative, denied these treatments, citing a lack of supporting medical literature at the time. However, coverage for these therapies began in 2020 when new medical evidence emerged. Despite this, the insurer refused to cover treatments administered before 2020, prompting the lawsuit under the MHPAEA that mandates equal coverage for mental and physical health conditions. 

The plaintiffs then focused on their claim that the insurer’s actions violated the MHPAEA, which mandates equal treatment limitations for mental and physical health benefits. They argued that the insurer applied the “evidence-based” requirement more stringently to autism therapies than to chiropractic care, which they claimed lacked scientific support. 

Equal Footing for Mental and Physical Conditions 

The Plaintiff’s argument centered on the MPHAEA’s requirement for equal treatment. They claimed that denying autism therapies while covering less scientifically supported treatments like chiropractic care for musculoskeletal conditions was a violation of the Act. However, the court found that the difference in treatment was due to variations in the available medical literature, not biased treatment of mental versus physical conditions. 

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