Docket: EBSA-2009-0010 

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 

Comment On: EBSA-2009-0010-0409 

Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0678 

Comment on FR Doc # 2010-2167 

Submitter Information 

Name: Cynthia Kerson, PhD 

Address: 

1925 Francisco Blvd. E #12 

San Rafael, CA, 94901 

Email: office@isnr.org 

Phone: 415-485-1344 

Organization: International Society for Neurofeedback and Research 

General Comment 

We are very supportive of most of the provisions of the interim final rules under the Paul 

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. These rules 

address many of the inequities in health insurance coverage of mental health care when 

compared to medical/surgical care that we have observed in the course of my mental health 

practice. 

However, in our opinion, two areas have not been sufficiently clarified. We are quite concerned 

that unless these points are more clearly specified in the final regulations, loopholes will remain 

that will permit widespread violation of the legislative intent of the Paul Wellstone and Pete 

Domenici Mental Health Parity and Addiction Equity Act of 2008: 

1. In our opinion, the interim final rules do not define clearly enough the rules regulating the 

comprehensive scope of services parity between mental health/substance abuse services and 

medical/surgical services. Given the language of the Act and the positions already taken by the 

Departments in the interim final regulations, we request that the Final Rules clarify that benefits 

for MH/SUD must be comparable in scope to the benefits provided in medical/surgical care both 

across and within each classification. Unless parity in scope of services is required in the final 

regulations, the intent of the Act will not be achieved. 

2. We strongly support the application of parity requirements to both QTLs and NQTLs as being 

consistent with the Act and allowing for broad application of the parity requirement with regard to 

treatment limitations. However, in order to implement the intent of the Act, the regulations must 

PUBLIC SUBMISSION

As of: May 03, 2010 

Received: May 02, 2010 

Status: Pending_Post 

Tracking No. 80ae556d 

Comments Due: May 03, 2010

Submission Type: Web

Page 1 of 2

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specify more clearly that any NQTLs that are applied by plans must be comparable for MH/SUD 

and medical surgical benefits, and that any NQTLs for MH/SUD must be no more restrictive than 

NQTLs that are predominant across the broad range of medical/surgical benefits.Thank you, ISNR 

Board of Directors 

Attachments 

EBSA-2009-0010-DRAFT-0678.1: Comment on FR Doc # 2010-2167

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https://fdms.erulemaking.net/fdms-web-agency/component/submitterInfoCoverPage?Call=P... 5/3/2010
Comments RE: Interim Final Rules under the Paul Wellstone and Pete Domenici Mental Health Parity and

Addiction Equity Act of 2008

We are The International Society for Neurofeedback and Research

We are very supportive of most of the provisions of the interim final rules under the Paul Wellstone and Pete

Domenici Mental Health Parity and Addiction Equity Act of 2008.  These rules address many of the inequities in

health insurance coverage of  mental health care when compared to medical/surgical care that we have

observed in over 18 years of being a member organization in the field of neurotherapy.  

However, in our opinion, two areas have not been sufficiently clarified. We are quite concerned that unless

these points are more clearly specified in the final regulations, loopholes will remain that will permit widespread

violation of the legislative intent of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction

Equity Act of 2008:

1. In our opinion, the interim final rules do not define clearly enough the rules regulating the

comprehensive scope of services parity between mental health/substance abuse services and

medical/surgical services. Given the language of the Act and the positions already taken by the

Departments in the interim final regulations, we request that the Final Rules clarify that benefits for

MH/SUD must be comparable in scope to the benefits provided in medical/surgical care both across and

within each classification.  Unless parity in scope of services is required in the final regulations, the

intent of the Act will not be achieved.

2. We strongly support the application of parity requirements to both QTLs and NQTLs as being consistent

with the Act and allowing for broad application of the parity requirement with regard to treatment

limitations.  However, in order to implement the intent of the Act, the regulations must specify more

clearly that any NQTLs that are applied by plans must be comparable for MH/SUD  and medical surgical

benefits, and that any NQTLs  for MH/SUD must be no more restrictive than NQTLs that are

predominant across the broad range of medical/surgical benefits.  

The importance of the question of parity of scientific review criteria is well illustrated by experience with

EEG biofeedback for the treatment of many disorders. Please refer to

http://isnr.org/ComprehensiveBibliography.cfm for a comprehensive bibliography of the published

literature in our field.

These same insurers however cover many medical surgical services with far inferior scientific support.  Much

more stringent and restrictive criteria are employed in scientific review of mental health and substance abuse

treatments than are met for the preponderance of medical surgical treatment. The result is an egregious

violation of the principles of parity and equality.

To give just one of many possible examples: The Journal of the American Medical Association (JAMA)

recently published a review of the evidence base supporting the joint cardiovascular practice guidelines

of the American College of Cardiology (ACC) and the American Heart Association (AHA). (Tricoci P, Allen

J, Kramer J, Califf R, Smith S (2008) Scientific Evidence Underlying the ACC/AHA Clinical Practice

Guidelines, JAMA, February 25, 2009—Vol 301, No.8 )

In this review, the 16 current practice guidelines that reported levels of scientific evidence were reviewed and

the degree of scientific support for 2711 specific practice recommendations was assessed and paced into one of

three categories:
• Level of evidence A: recommendation based on evidence from multiple randomized trials or meta analyses

• Level of evidence B: recommendation based on evidence from a single randomized trial or nonrandomized

studies

• Level of evidence C: recommendation based on expert opinion, case studies, or standards of care.

The results show that only 11% of the 2711 recommendations are based on level of evidence A – multiple

randomized trials. Of the remaining recommendations, 41% are based on level of evidence B – a single

randomized trial or non‐randomized studies, and 48% are based on level C – expert opinion or case studies.

This makes it clear that at least in cardiology, the actual scientific review criteria currently in use in the

predominant body of medical surgical practice, at least in cardiology, are less restrictive than those routinely  

employed for scientific review of mental health and substance abuse treatment and include anecdotal evidence

(expert opinion), case studies, non‐randomized studies, or a single randomized trial.  Specifically, health insurers

routinely limit reimbursement of EEG biofeedback as lacking scientific evidence, despite the fact that there is

stronger evidence than for many covered services in cardiology.  

For this reason, it is critically important, in order to implement the Paul Wellstone and Pete Domenici Mental

Health Parity and Addiction Equity Act of 2008, that the regulations specify more clearly that any NQTLs that are

applied by plans must be comparable for MH/SUD and medical surgical benefits, and that any NQTLs for

MH/SUD must be no more restrictive than NQTLs that are predominant for all medical/surgical benefits.  

Thank you for your careful consideration of these requests.

Sincerely,

The Board of Directors of the International Society for Neurofeedback and Research