Wednesday, January 28, 2015

Sample Medical Order, Letter of Medical Necessity and Appeal Letter for #ABA Services

From The Arc Autism Insurance Project in collaboration with Family Voices Indiana and About Special Kids

Feel free to contact Family Voices Indiana at 317 944 8982 or info@fvindiana.org if you need additional resources or support.


Sample Medical Order, Letter of Medical Necessity and Appeal Letter for ABA Services – Medicaid under EPSDT (ages 0-21)

EPSDT – Early, Periodic Screening Diagnosis and Treatment

MEDICAL TREATMENT ORDER SAMPLE FORMAT

The prescribing physician should include:

  1. Physician’s order for ABA therapy
  2. Letter of medical necessity written by the physician or ABA provider, which includes:
    1. Patient history
    2. Diagnosis and prognosis
    3. Description of recommended services and explanation of why the services are medically necessary
    4. What the benefit to the patient will be, and
    5. Recommended length of time for the services

Medical Necessity
According to the Health and Human Services website:

Medical Necessity under EPSDT  
In a report prepared for the federal Health Care Financing Administration (HCFA, now known as Center for Medicare and Medicaid Services – CMS), Rosenbaum and Sonosky described the EPSDT medical necessity standard as follows:
"While there is no federal definition of preventive medical necessity, federal amount, duration and scope rules require that coverage limits must be sufficient to ensure that the purpose of a benefit can be reasonably achieved.... Since the purpose of EPSDT is to prevent the onset of worsening of disability and illness and children, the standard of coverage is necessarily broad... the standard of medical necessity used by a state must be one that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury but also, to prevent the development or worsening of conditions, illnesses, and disabilities."

ABA therapy treatment consisting of [describe medically necessary scope, duration, number of hours of front line, number of hours of BCBA supervision] is medically necessary for this individual.  

Provider or physician summarizes the DSM-V criteria and medical necessity criteria that the individual child fits.
  • Elements of medical necessity
    • Evidenced based practice – best available medical evidence or RCT “gold standard”
    • Goal is to remediate deficits, signs and symptoms of the condition being treated
    • Treatment plan must specify frequency, intensity and duration of treatment that is considered to be clinically appropriate
  • A less intensive and less costly treatment with the same level and quality of expected outcomes does not exist, has failed
  • Treatment is not primarily for the convenience of the patient, family or provider
Provider or Physician supplies a short summary of expected regression or worsening of disability/condition if treatment is not at sufficient level to meet need.



APPEAL LETTER SAMPLE FORMAT

To Whom It May Concern:

I am writing to appeal the decision to deny ABA services to [Name, Date of Birth, Medicaid Number].  The services as prescribed are medically necessary under EPSDT for this child.

According to the Health and Human Services website:

Medical Necessity under EPSDT  
In a report prepared for the federal Health Care Financing Administration (HCFA, now known as Center for Medicare and Medicaid Services – CMS), Rosenbaum and Sonosky described the EPSDT medical necessity standard as follows:
"While there is no federal definition of preventive medical necessity, federal amount, duration and scope rules require that coverage limits must be sufficient to ensure that the purpose of a benefit can be reasonably achieved.... Since the purpose of EPSDT is to prevent the onset of worsening of disability and illness and children, the standard of coverage is necessarily broad... the standard of medical necessity used by a state must be one that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury but also, to prevent the development or worsening of conditions, illnesses, and disabilities."

ABA therapy treatment consisting of [describe medically necessary scope, duration, number of hours of front line, number of hours of BCBA supervision] is medically necessary for this individual.  

Provider or physician summarizes the DSM-V criteria and medical necessity criteria that the individual child fits.
  • Elements of medical necessity
    • Evidenced based practice – best available medical evidence or RCT “gold standard”
    • Goal is to remediate deficits, signs and symptoms of the condition being treated
    • Treatment plan must specify frequency, intensity and duration of treatment that is considered to be clinically appropriate
  • A less intensive and less costly treatment with the same level and quality of expected outcomes does not exist, has failed
  • Treatment is not primarily for the convenience of the patient, family or provider
Provider or Physician supplies a short summary of expected regression or worsening of disability/condition if treatment is not at sufficient level to meet need.


Thank you for your prompt consideration of this matter,

Provider/Treating Physician Signature
Parent/Guardian/Caregiver Signature




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