By Ashleigh Evans, MS, BCBA
In the early 2000s, advocacy efforts pushed forward a medical model of ABA. This model gained momentum as states began passing autism insurance mandates. In 2014, the Centers for Medicare & Medicaid Services (CMS) published a bulletin clarifying that Medicaid programs must provide autism services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This set in motion plans across all 50 states for Medicaid programs to provide ABA and other services to Medicaid recipients. As of today, every US state also has insurance mandates requiring ABA therapy coverage, fully integrating ABA into the healthcare system.
The shift to a medical model of Applied Behavior Analysis (ABA) has brought benefits to the field, including increased access to care. However, with it also came increased treatment plan scrutiny from payors. Most payors now require BCBAs to demonstrate that a client meets medical necessity to authorize services. Let’s explore the concept of medical necessity and consider how clinicians can advocate for their learners.
What is Medical Necessity in ABA?
Medical necessity is a concept used within the healthcare field. It refers to treatment that is necessary to diagnose, treat, cure, or alleviate symptoms of a particular condition. When we look at medical necessity in ABA, we have to consider whether the therapy modality and specific individualized goals will realistically help relieve the symptoms of autism that are interfering with the learner’s quality of life.
Each payor has different medical necessity criteria. Generally speaking, to determine medical necessity, funders consider the type of care, frequency and duration, location where care will be provided, whether the treatment is research-backed, and whether it would be considered effective for the individual patient.
How to Demonstrate Medical Necessity
Behavior analysts are responsible for advocating for their clients–this includes advocating for medical necessity to enable their learners to receive medically necessary care. Here are some recommendations for navigating this requirement.
1. Understand the payor’s medical necessity criterion.
First, make sure you understand each payor’s criteria for medical necessity. Most major insurance providers publish medical necessity guidelines online under their Behavioral Health or Medical Policies. You can also access medical necessity criteria in your provider manual. If you can’t locate medical necessity criteria, reach out to your provider rep for guidance.
- Ensure up-to-date diagnostic assessments.
One component of medical necessity is typically a recent autism diagnosis. Most payors require comprehensive diagnostic evaluations every 3-5 years to verify the individual’s diagnosis. Keep an eye on the dates of diagnostic assessments and inform your clients when they’ll need a reassessment soon. Many providers have lengthy waitlists, so try to be proactive in urging families to get these scheduled.
Tip: If your client is due for a reauthorization but is overdue for a diagnostic re-evaluation, encourage the family to at least get it scheduled before you submit the authorization request. Many funders will recognize that diagnosticians have schedules that book out for months or even years, so the client may not be able to access a re-evaluation by the required date, but they at least want to see that it’s scheduled. - Conduct insurance-approved assessments at least every 6 months.
Make sure you have an updated and accurate assessment on file. Certain payors only accept specific assessment tools, so be sure to verify which assessments are accepted by the funder.
- Add a rationale for each goal.
In your treatment plan, add a justification for each treatment goal. This justification should tie back to the diagnostic criteria of autism spectrum disorder (ASD). In other words, specifically, how will targeting the goal alleviate the symptoms of ASD? Per the DSM-5, diagnostic criteria for autism include:
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
- Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
- Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
Here’s an example of a justification statement for an ABA treatment goal:
Goal: Client will independently mand for preferred items in 80% of opportunities, across 10 consecutive sessions, by 10/09/2025.
Rationale: To remediate the deficits in social communication that limit the client’s ability to get their needs and wants met.
5. Make sure the hours you’re requesting match the learner’s needs.
Lastly, ensure the hours of ABA you are requesting match the learner’s needs. If the individual has minimal needs or if you aren’t effective in communicating the full scale of their needs within the treatment plan, the funder may deem that services at the requested level are not medically necessary. Consider the whole picture of the learner’s abilities, needs, other services, and school supports to determine clinical need.
Main Takeaways
Behavior analysts are responsible for advocating for their clients’ best interests. While navigating the complexities of insurance and Medicaid can be challenging, it can be done effectively. Take time to understand each payor’s criteria and create a comprehensive treatment plan that directly addresses the funder’s requirements for demonstrating medical necessity.
About the Author
Ashleigh Evans, MS, BCBA, is a Board Certified Behavior Analyst. She has been practicing in the behavior analysis field for over 13 years and opened her own independent practice in early 2022. Her experience has been vast across different age groups, diagnoses, and needs. She is passionate about improving the field through education, reformative action, and better supervisory practices, leading her to create content and resources for families and ABA professionals which can be found on her website, www.abaresourcecenter.com