Securing insurance coverage for certain therapies often requires justifying the need for such services. Despite Applied Behavior Analysis (ABA) therapy being a well-established evidence-based treatment approach for individuals with autism spectrum disorder (ASD) and other developmental disorders, insurance companies still require justification due to its intensity and costs. The justification can be claimed in a letter of medical necessity.
This article will explain a letter of medical necessity, what it entails, and how to write one.
What is a Letter of Medical Necessity for ABA Therapy?
A letter of medical necessity for ABA therapy is a comprehensive and persuasive explanation of why ABA therapy is specifically necessary for an individual’s health and well-being. It is a vital document in the process of obtaining insurance coverage for specialized services such as ABA therapy. The letter of medical necessity not only justifies treatment, but it creates transparency and provides a basis for decision-making.
While coverage for ABA therapy varies based on your location and insurance plan, many private insurance companies require this letter to provide coverage for ABA therapy. The following are common insurance companies that may require or request a letter of medical necessity for ABA coverage:
- Blue Cross Blue Shield (BCBS)
- UnitedHealthcare (requires support documentation as well as a letter of medical necessity)
Most states also have specific autism mandates, which require certain insurers to provide coverage for autism spectrum disorder. The following states are exceptions or have specific limitations to the coverage, such as requiring a board-certified and supervised expert to deliver ABA services: California, Indiana, Georgia, Montana, and Arkansas.
Insurance requirements can change, and coverage may vary depending on individual policies, state regulations, and the specific needs of the individual requiring services. It is important to first verify the current requirements with your provider to ensure the accurate processing of coverage requests.
(NOTE: If you have not yet found an ABA therapy provider, our free matching tool below can connect you with one nearby)
What Must the Letter Contain?
The specific requirements will vary depending on the insurance provider and individual’s policy but most letters of medical necessity must contain the following:
- Primary medical provider information.
- Patient information: name, date of birth, and history.
- Diagnosis and specific symptoms experienced by the individual.
- Description of ABA therapy and clear recommendation for ABA therapy.
– Include the specific benefit of ABA for the individual who requires the service.
- Recommended hours per week and length of time for ABA services.
-It should also differentiate the number of hours for ABA in the home, at school, or in a clinical setting.
Who Must The Letter Come From?
Many insurance providers require a pediatrician or neurologist who has seen the child within the last six months to sign all letters of medical necessity for ABA services. The letter can be written by a Board-Certified Behavior Analyst (BCBA) and signed by the physician, or the letter can be written by the physician and the BCBA provides additional supporting letters. If the BCBA provides additional supporting letters, they must include a brief concurrence statement at the end of the letter from the physician. Since the letter must outline the specific benefit and treatment plan for ABA services it is more advantageous if the physician writes the letter in conjunction with the BCBA.
While it is most typical for healthcare professionals such as pediatricians or BCBAs to write a letter of medical necessity, parents and legal guardians play a crucial role in advocating for services and can write a letter of medical necessity. Many insurance providers still require a physician’s signature; therefore, it is ideal for the parent to collaborate with the physician or BCBA in writing the letter. Their firsthand knowledge and experience of the child in combination with the medical professional’s perspective and treatment knowledge can result in a strong argument for service coverage.
Sample Letter of Medical Necessity for ABA Therapy
[City, State, Zip Code]
[Insurance Company Name]
[City, State, Zip Code]
Re: [Patient Name]
DOB: [Patient’s Date of Birth]
Policy Number: [Patient’s policy number]
Dear [Insurance Company Name] Medical Review Department,
I am writing to advocate for the medical necessity of Applied Behavior Analysis (ABA) therapy for [Patient Name], who is a [patient age] child diagnosed with [Patient’s diagnosis] on [date of diagnosis]. A Board-Certified Behavior Analyst has conducted a comprehensive assessment of [Patient Name] and has determined that ABA therapy is necessary for their overall development.
[Patient Name] has been diagnosed with [Patient’s diagnosis] as confirmed by [Diagnosing Professional’s Name]. [He/She] presents with significant challenges in [list of challenge areas]. The patient exhibits [list of symptoms]. The severity of these deficits significantly impairs [his/her] ability to engage in age-appropriate social and educational activities, thus impeding [his/her] overall quality of life.
Research consistently supports the effectiveness of ABA as a therapeutic intervention for those with Autism and other developmental disorders. ABA is a data-driven, evidence-based approach that focuses on teaching and reinforcing socially significant behaviors while reducing challenging or maladaptive behaviors.
[Patient Name] Individualized Treatment Plan:
Based on the assessment results a comprehensive and individualized treatment plan has been developed for [Patient Name]. The treatment plan utilizes strategies that are evidence-based and align with best practices in the ABA field. The goals of ABA for [Patient Name] are as follows:
[List of Goals with measurable outcomes]
Duration and Intensity of Treatment
Considering [Patient Name] unique needs, it is recommended that [he/she] receive a minimum of [number of hours] hours of ABA therapy per week, for a duration of [length of time for ABA therapy]. The duration and intensity of ABA therapy are necessary to provide the support and intervention required to make a meaningful impact on [Patient Name]. Ongoing assessment and analysis of the treatment plan will be conducted to ensure the outlined plan is effective and implemented accurately.
I kindly request that [Insurance Company Name] provide the necessary coverage for ABA therapy. Enclosed with this letter you will find supporting documentation, including the diagnostic evaluation, assessment results, individualized treatment plan, and all objective data collected. I am available to discuss any additional information or answer any questions that may aid the review process.
Tips for Writing a Letter of Medical Necessity
While there is no one-size-fits-all format for a letter of medical necessity, the following are some tips to keep in mind when writing one for ABA services:
- It is important to keep the letter short and to the point.
- Avoid jargoned language. Ensure the letter is written clearly and it is easily understood.
- Be as specific as possible. This applies to the symptom description and the benefits of ABA therapy for those symptoms.
- Ensure the letter is presented from a fact-based, objective perspective rather than an opinion, or subjective viewpoint.
- Ensure statements regarding the consequences of behaviors are written as actual outcomes and not hypothetical outcomes.
- Support the need for ABA therapy by referencing research studies outlining the benefits of similar treatment plans.
- Review previous treatment courses that were ineffective.
- Explain how ABA services could reduce the need for other costly treatments or equipment.
- Discuss the long-term prognosis with and without ABA services.
- Be unique and ensure to depict the individual with autism as a real person who can overcome challenges with this treatment approach.
Should You Include Documentation With The Letter?
Some private insurance companies, such as UnitedHealthcare, require additional documentation to ensure coverage for ABA therapy. However, even if additional documentation is not mandatory, it is good practice to provide it as support for medical necessity. In addition, by including support documentation, the letter of medical necessity can be more concise. If the insurance provider requires more information before making a decision, that information can be taken from the support documentation.
- Diagnostic reports confirming the child’s diagnosis and need for ABA.
- Functional behavioral assessments and intake assessments that outline how the diagnostic criteria are present in the child, risks, and client functioning.
- Individual service/treatment plan, which includes overall goals and measurable objectives, clear descriptions of intervention and service types, and baseline data.
- Progress reports that outline the impact of treatment on symptoms or the progress towards the objectives, an ongoing analysis of the treatment strategy, and a continuous need for the treatment approach.
- Educational or school reports that outline the child’s difficulties in the educational setting.
- Photographs and videos can display specific behavioral challenges that ABA services will be addressing.
- Parental or caregiver statements that outline the impact of the child’s symptoms on daily living and expressing their need for ABA services.
If you are unsure of what information is required, or of how that information should be written, the best course of action is to reach out to the insurance company directly. The company representative can direct you to most appropriate resource or person to find the answers you need to secure coverage of services.