Page posted: 6/8/15
Page reviewed: 2/17/17
Page updated: 2/12/18
Medical necessity determination: A decision made by a qualified professional about whether a person with autism spectrum disorder (ASD) or a related condition has a medical need for and, therefore, is eligible to receive EIDBI services.
A comprehensive multi-disciplinary evaluation (CMDE) provider determines a person’s initial medical need and eligibility for EIDBI services during the CMDE process. This page explains the medical necessity criteria for EIDBI services. For eligibility criteria, see EIDBI – Eligibility for EIDBI services. For information about the CMDE, see EIDBI – CMDE.
The CMDE provider makes treatment recommendations based on the medical necessity determination. The medical necessity determination and treatment recommendations provide the basis for developing the person’s individual treatment plan (ITP). For information about the ITP, see EIDBI – ITP development and progress monitoring. For information about service authorization, see MHCP Provider Manual – EIDBI – service authorization.
Subsequent reauthorizations of EIDBI services or changes in EIDBI services require other medical necessity determinations, which are explained on this page.
A person has a medical need to begin EIDBI services if he or she meets all of the following criteria:
1. The person’s symptoms are present in the early developmental period, or the symptoms either:
2. The person’s behaviors persist in frequency, intensity and duration across environments
4. Based on the CMDE, the person requires 10 or more hours a week of EIDBI services
Under age five
If the person is under age five, he or she may not have an ASD or related condition diagnosis but still meet medical necessity criteria. For more information, see exception to diagnostic criteria on EIDBI – Eligibility for EIDBI services.
Medical necessity treatment guidelines
The treatment recommendation should be at least 10 hours of EIDBI services per week. For a person over age seven, the treatment recommendation should not exceed 20 hours of EIDBI services per week.
Consider the following when recommending treatment:
EIDBI – Medical necessity treatment determination guidelines provides a framework to make treatment recommendations based on the:
Some circumstances may allow for exceptions to medical necessity treatment guidelines.
Less than 10 hours
The review agent may approve less than 10 hours of EIDBI services per week if at least one of the following are true:
Once the provider submits DHS-7108 and DHS-7109 for authorization, the review agent will evaluate the rationale and determine if it is medically appropriate for the person to receive less than 10 hours per week of EIDBI services. For more information about service authorization, see MHCP Provider Manual – EIDBI – service authorization.
More than 20 hours for a person older than age seven
The review agent may approve more than 20 hours of EIDBI services per week for a person older than age seven if at least one of the following are true:
Once the provider submits DHS-7108 and DHS-7109 for authorization, the review agent will evaluate the rationale and determine if it is medically appropriate for the person to receive more than 20 hours per week of EIDBI services. For more information about service authorization, see MHCP Provider Manual – EIDBI – service authorization.
Reauthorization of EIDBI services
All of the following criteria must be met before EIDBI services are reauthorized:
1. The person continues to meet medical necessity criteria for EIDBI services, as documented in the CMDE, DHS-7108
3. The QSP determines that the person will continue to benefit from the prescribed EIDBI services based on documented progress
A change in the intensity level of EIDBI services (increase or decrease) may be determined medically necessary for one or more of the following reasons:
1. Person starts school
For information about how to request a change in EIDBI service intensity, see EIDBI – Intervention.
Termination of EIDBI services
Termination of EIDBI services may be determined medically necessary for one or more of the following reasons:
1. The person has achieved maximum benefit from EIDBI services, as documented by measurable progress on and generalization of goals and objectives across environments and people
6. The parent/ or legal guardian requests termination of services
Additional information about termination of services
For more information about termination of services, see the termination of services section on EIDBI – EIDBI services and the transition and discharge planning section on EIDBI – How to complete ITP and Progress Monitoring, DHS-7109
Re-starting EIDBI services after termination
To re-start EIDBI services after a person’s EIDBI services were terminated, the EIDBI provider should provide a rationale in the ITP, DHS-7109 for why EIDBI services are now recommended.
If the person’s CMDE is more than 12 months old, the person must receive a new CMDE, DHS-7108 and meet the medical necessity criteria to re-start EIDBI services.
CMDE Medical Necessity Summary Information, DHS-7108