Seventh Circuit Rules on Therapy Limitations for Autism under the MHPAEA

August 28, 2024

On August 5, 2024, the Seventh Circuit Court of Appeals (Seventh Circuit) affirmed the district court’s ruling in favor of insurer Group Health Cooperative (the defendant) when they denied claims for therapy treatment brought by parents on behalf of their autistic child (plaintiffs) based upon then-current medical literature.

The plaintiffs asked the defendant health insurer to pay for certain treatments for their autistic child that occurred between 2017 and 2019. The defendant refused to pay since the medical literature at the time did not support speech therapy as a treatment for autism for a child at the relevant age and did not support the use of sensory integration therapy (a form of occupational therapy) as a treatment for autism at any age. The defendant began covering these treatments after 2020, when the medical literature changed; however, they did not cover the plaintiffs’ earlier claims. After exhausting their administrative appeals, the plaintiffs sued the defendant and alleged violations of ERISA, state law regarding the coverage for autism, and the MHPAEA. The district court found that the defendant could rely on the relevant medical literature at the time the claims were made and ruled in favor of the defendant.

The plaintiffs’ appeal focused on the alleged violation of MHPAEA. The plaintiffs argued that the insurer's requirement for treatments to be "evidence-based" was applied more stringently to mental health benefits for autism than to medical benefits, violating MHPAEA. In support of this argument, the plaintiffs compared the therapies at issue in the case with chiropractic care for musculoskeletal conditions in pediatric patients, a treatment that the defendant did cover, and which the plaintiffs contended lacked scientific support. The district court, however, found that the insurer's policies reflected the differing focus of medical literature on autism and musculoskeletal conditions, with the former often considering efficacy by age due to the nature of autism diagnosis and treatment. The court concluded that the insurer was entitled to rely on the available medical literature when determining treatments to cover if the process applied to both mental health and medical benefits.

In addition, the plaintiffs focused on only one medical benefit to compare to the therapies at issue in the case. The court determined that MHPAEA requires that treatment limitations applicable to mental-health benefits be no more restrictive than treatment limitations “applied to substantially all” medical and surgical benefits covered by the plan. Although the court did not determine exactly what “substantially all” meant in this context, they did conclude that it meant more than one. The court concluded that the plaintiffs could not establish that substantially all medical benefits under the plan were less restrictive by comparing the treatment limitations of just one medical treatment with the therapies at issue with the case. Ultimately, the insurer's practices were deemed consistent with the MHPAEA, as the act allows for reliance on medical literature when assessing treatments, regardless of the type of benefit, and the Seventh Circuit affirmed the district court’s ruling in favor of the defendant.

Employers should be aware that plans can rely on current medical literature when determining whether a particular treatment or therapy can be covered. Additionally, employers should compare their mental health benefits to substantially all medical and surgical benefits covered by their plan to evaluate whether mental health benefits are in parity with medical and surgical benefits.

Midthun-Hensen on behalf of K.H. v. Grp. Health Coop. of S. Cent. Wisconsin, Inc.