Sample Physician Letter of Medical Necessity

Last updated Thursday, July 26, 2012   |   comments
SAMPLE LETTER OF MEDICAL NECESSITY: ABA INTERVENTION FOR AUTISM

When you initially apply for insurance, you will need a prescription or a letter of prescribed treatment written by the attending physician.  Although, not as common today, insurance companies, especially in non-mandate states may make the claim that ABA-based services are not medically necessary as they do not cure anything.  The same arguments can be made against many far more expensive treatments for heart disease and cancer.  It’s best to get out front and provide the template below to submit with your request. Make sure your doctor understands that you are not looking for a kinder, more gentle diagnosis but one that is succinct and presents the problem in the full. After you have been involved in the adventure of securing autism services for your child, it's easy to take for granted that other people share your sense of urgency around the ABA issue and have no reason to question ABA-based therapeutic interventions. It's best to assume otherwise. Make it as easy as possible for your physician by providing this template via email or CD.

While it may take time to move down the pipeline, in a mandated biennial review of the new federal Mental Health Parity law issued in January 2012, it stated that insurers need to provide a definition of "medical necessity." You may want to request that definition before crafting the letter.

Date:July 18, 2012
To: Name of Insurance  Company
RE: ABA services for (NAME OF CHILD)
Policy Number:
Group Number:


To Whom It May Concern:

After a careful and thorough diagnosis, it is my professional opinion as a physician treating [Child’s Name] that [Child’s Name] requires Applied Behavior Analysis (ABA)-based intervention services as a medically necessary treatment for [list autism diagnosis with DSMIV codes 299.00].  It is my belief that the immediate initiation of services will have a direct and positive impact upon the child's speech and language and social skills as well as his cognitive and physical functioning.

These services should be designed and supervised by a Board Certified Behavior Analyst (BCBA) in good standing and carried out by a BCBA or a  Board Certified Associate Behavior Analyst (BCaBA). These services  should be provided to the child in his or her natural environment of home at least 25 hours per week for a duration of 2 years, at which time it should be determine if services need to continue, be ended, or adjusted..  Progress review schedules and the need for periodic adjustments should be determined by the supervising BCBA. The initiation of these services does not preclude the need for additional therapeutic services that may be needed in the future.

While I believe that we are well past this point of discussion, just in case, anyone reviewing this recommendation believes that ABA-based services for children with autism is experimental, please consider the seminal research studies listed below. Reach continues tto build on more four decades of evidence that ABA-based interventions are the most effective approach for improving the ability of children with autism to enjoy lives of inclusion and contribution.
In addition to countless independent researchers, many national and state organizations continue to recognize ABA-based therapy as the most effective treatment for children with autism. These include the Centers for Disease Control, National Institutes of Health, Federal Drug Administration, and the office of the U.S. Surgeon General. This argument is also supported by the U.S. Department of Defense  which continues to provide ABA services to military families raising children with autism through its TRICARE ECHO program.




Experimentally Controlled Studies
  • Anderson, S. R., Avery, D. L., DiPietro, E. K., Edwards, G. L., & Christian, W. P. (1987). Intensive home-based intervention with autistic children. Education and Treatment of Children,10, 352–366.
  • Birnbrauer, J. S., & Leach, D. J. (1993). The Murdoch Early Intervention Program after 2 years. Behavior Change, 10, 63–74..
  • Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children.  Journal of Consulting Clinical Psychology, 55, 3-9.
  • McEachin, J. J., Smith, T., & Lovaas, O. I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97, 359–372.
  • Sheinkopf, S. J., & Siegel, B. (1998). Home-based behavioral treatment of young children with autism. Journal of Autism and Developmental Disorders, 28, 15–23.
  • Smith, T., Groen, A., & Wynn, J. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. American Journal on Mental Retardation, 105, 269–285.
  • Weiss, M. J. (1999). Differential rates of skill acquisition and outcomes of early intensive behavioral intervention for autism. Behavioral Interventions, 14, 3–22.
Reviews of Research Supporting Intensive ABA for Children with Autism
  • Maine Administrators of Services for Children with Disabilities (1999). Report of the MADSEC Autism Task Force. MADSEC, Manchester, ME.
“Over 30 years of rigorous research and peer review of applied behavior analysis’ effectiveness for individuals with autism demonstrate ABA has been objectively substantiated as effective based upon the scope and quality of science.”
“Early interventionists should leverage early autism diagnosis with the proven efficacy of intensive ABA for optimal outcome and long-term cost benefit.”
“The importance of early, intensive intervention for children with autism cannot be overstated.”
  • New York State Department of Health Early Intervention Program. (1999). Clinical Practice Guideline Report of the Recommendations for Autism/Pervasive Developmental Disorders. New York State Department of Health, Albany, NY.
“Based upon strong scientific evidence, it is recommended that principles of applied behavior analysis and behavior intervention strategies be included as an important element of any intervention program for young children with autism.”

  • Volkmar, F., Cook, E.H., Pomeroy, J., Realmuto, G. & Tanguay, P. (1999). Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (Supplement), 32s-54s
“Early and sustained intervention [programs] appear to be particularly important…Such programs have typically incorporated behavior modification procedures and Applied Behavior Analysis.”

 “It is clear that behavioral interventions can significantly facilitate acquisition of language, social, and other skills and that behavioral improvement is helpful in reducing levels of parental stress.”

  • Satcher, D. (1999). Mental health: A report of the surgeon general. U.S. Public Health Service. Bethesda, MD
"Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior.”


Please do not hesitate to be touch, if more information is required.

Sincerely,


____________________________________
Medical Doctor’s Signature and title





 
 
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