Page posted: 6/8/15
Page reviewed: 2/17/17
Page updated: 12/15/17
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.
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.
3. The person’s behaviors also either:
4. Based on the CMDE, the person requires 10 or more hours a week of EIDBI services.
5. Less intensive treatment options for the person have been considered.
6. The CMDE provider determines that the interventions covered by EIDBI services will appropriately target the core deficits of the person with a diagnosis of ASD or a related condition.
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:
Some circumstances may allow for exceptions to medical necessity treatment guidelines.
Less than 10 hours
DHS may approve less than 10 hours of EIDBI services per week if one or more of the following are true:
1. Person is under age three.
2. Parent/primary caregiver requests fewer hours.
3. CMDE provider recommends less than 10 hours of EIDBI services per week and documents rationale in the CMDE, DHS-7108.
4. The ITP, DHS-7109 documents other services the person receives which indicate a need for less than 10 hours of EDIBI services per week.
More than 20 hours for a person older than age seven
DHS 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:
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.
2. The ITP documents:
3. The qualified supervising professional (QSP) determines that the person will continue to benefit from the prescribed EIDBI services based on documented progress.
4. The progress on overall goals documented in the ITP, DHS-7109 indicates that reasonable progress is expected to continue.
5. The parent or legal guardian signs the ITP, DHS-7109, documenting his or her continued agreement with and consent for EIDBI services.
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.
2. Person transitions from EIDBI to other services.
3. Significant change in the family.
4. Increase or decrease in other related services.
5. CMDE provider or QSP recommends a change in the intensity level of EIDBI services and documents rationale.
6. Parent or legal representative requests a change in the intensity level of EIDBI services and the CMDE provider or QSP documents supportive rationale.
7. Person received the recommended treatment amount and did not make progress.
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.
2. The person no longer meets medical necessity criteria for EIDBI services.
3. EIDBI services make the person’s symptoms persistently worse.
4. The person is not making progress toward individual treatment goals. This lack of progress is demonstrated by the absence of any documented, sustainable, generalized and measurable progress.
5. The person has not shown signs of or the provider does not reasonably expect the person to show signs of measurable progress within 12 months of the initial ITP development. This is demonstrated by both:
6. The parent/ or legal guardian requests termination of services.
7. The CMDE provider or QSP recommends a termination of services because the person would likely benefit from another service or be more appropriately served by less-intensive forms of treatment.
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 (PDF)