Cigna Slapped with Class Action Autism Suit

A federal judge in Philadelphia entered an order today granting class action status to a case filed by families against Cigna Insurance for allegedly denying claims for Applied Behavior Therapy (ABA), a technique that involves using modern behavioral learning theory to modify overt behaviors to treat autism. The ruling means the case will now be brought on behalf of all persons who filed a claim with CIGNA for ABA therapy for a child having autism spectrum disorder, but no longer have CIGNA insurance, where such claim was denied on the ground that such therapy was allegedly "experimental."

The ruling was made by Honorable Juan Sanchez in the case of Churchill v CIGNA, No. 10-6911 (ED PA). The Court's Memorandum Opinion explained that class action status on behalf of all similarly situated families was appropriate given CIGNA's national policy of denying ABA therapy on the ground that it is "experimental."

The families' attorneys, Gerard Mantese and John Conway, noted that numerous authorities have found ABA to be a scientifically valid treatment for children with autism, including the United States Surgeon General, the National Institute of Mental Health, the American Academy of Pediatrics, and a study commissioned for both the Medicare and Medicaid systems. At present, 26 states mandate insurance coverage for ABA therapy, noted the attorneys.

However, Cigna, in a “Medical Necessity Guideline for the Treatment of Autism Specturym Disorders,” notes that within the Applied Behavioral Analysis (ABA) provider field, there is general recognition of two types of ABA. Type 1 ABA refers to narrowly targeted interventions for specific problematic behaviors, and Type 2 ABA refers to those broader behavioral interventions aimed at a wider range of skills building activities (usually applicable to behaviors that impair social interaction, communication, and adjustment to the environment).

According to the guideline, prior to authorizing ABA, Aetna requires a level of maladaptive behavior for which ABA represents clinically appropriate effective treatment.

“Many Aetna plans exclude coverage for services considered to be educational in nature, and this would apply to ABA. In the absence of a state mandate, or plan language including ABA (or more commonly, no plan language excluding coverage for educational services), Aetna would consider ABA to be an educational service and therefore, not covered. In situations where there is coverage (mandated or not excluded), there is insufficient scientific support to determine in advance the optimal frequency, duration or intensity of ABA needed for a particular individual or a particular behavioral target symptom. In the absence of such an evidence base, and to allow for incorporation of resources (such as early intervention, speech therapists, or special education), Aetna would consider no more than 20 hours per week for 60 consecutive days, as sufficient to meet the definition of “intensive” in the AAP statement quoted above.”

It is unclear as to the type of ABA required per claimant; Aetna could not be reached for further comment.