CMS-approved state plan amendment – 2017 (PDF), CMS-approved state plan amendment – 2018 update (PDF), CMS-approved state plan amendment – 2019 update (PDF), Minn. Stat. §256B.0949

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 service eligibility criteria, refer to EIDBI – Eligibility for EIDBI services. For information about the CMDE, refer to 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, refer to EIDBI – ITP development and progress monitoring. For information about service authorization, refer to 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 they meet all 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 either:

4. Based on the CMDE, the person requires 10 or more hours per week of EIDBI services (unless there is a clinical rationale for an exception).

5. The CMDE provider determines the interventions covered by EIDBI services will appropriately target the core characteristics of the person with ASD or a related condition.

Younger than age five

If the person is younger than age five, they may not have an ASD or related condition diagnosis but still meet medical necessity criteria. For more information, refer to exception to diagnostic criteria on EIDBI – Eligibility for EIDBI services.

The treatment recommendation should be at least 10 hours per week of EIDBI services. For a person older than age seven, the treatment recommendation should not exceed 20 hours per week of EIDBI services.

The provider should consider the following when recommending treatment:

Framework

EIDBI – Medical necessity treatment determination guidelines provides a framework to make treatment recommendations based on:

Exceptions

Some circumstances may allow for exceptions to medical necessity treatment guidelines.

Fewer than 10 hours

The review agent may approve fewer than 10 hours of EIDBI services per week if at least one of the following situations is 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 fewer than 10 hours per week of EIDBI services. For more information about service authorization, refer to 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 situations is 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, refer to MHCP Provider Manual – EIDBI – Service authorization.

Medical necessity review only

If the provider submits a comprehensive evaluation completed by an outside CMDE provider (i.e., not within the treating EIDBI agency), they must make sure the CMDE is complete and submit it to the medical review agent for medical necessity review only before they submit the treatment plan for authorization.

All the following criteria must be met before the medical review agent reauthorizes EIDBI services:

1. The person continues to meet medical necessity criteria for EIDBI services, as documented in the CMDE.

2. The ITP documents:

3. The QSP determines the person will continue to benefit from the recommended EIDBI services based on documented progress.

4. The progress on overall goals documented in the ITP indicates reasonable progress is expected to continue, or EIDBI services are required to ensure the person maintains the skills.

5. The person’s parent or legal representative signs the ITP to document continued agreement with and consent for EIDBI services.

A qualified professional may determine a change in the intensity level of EIDBI services (i.e., increase or decrease) is medically necessary for one or more of the following reasons:

1. The person starts school.

2. The person transitions from EIDBI to other services.

3. The person experiences a significant change in their life or their family.

4. The person experiences an increase or decrease in other related services.

5. The CMDE provider or QSP recommends a change in the intensity level of EIDBI services and documents rationale.

6. The parent or legal representative requests a change in the intensity level of EIDBI services, and the CMDE provider or QSP documents supportive rationale.

7. The person received the recommended treatment amount and did not make progress or maintain skills.

For information about how to request a change in EIDBI service intensity, refer to EIDBI – Intervention.

A qualified professional may determine termination of EIDBI services is 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, or EIDBI services are not required to ensure skills are maintained.
Note: This lack of progress is demonstrated by the absence of any documented, sustainable, generalized and measurable progress.

5. The person has not shown signs, or the provider does not reasonably expect the person to show signs, of measurable maintenance of skills or progress within 12 months of the initial ITP development. This is demonstrated by both:

6. The parent or legal representative requests termination of services.

7. The CMDE provider or QSP recommends a termination of services because:

Additional information about termination of services

For more information about termination of services, refer to 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

To restart a person’s EIDBI services after service termination, the EIDBI provider should use the person’s ITP to explain why they recommend EIDBI services now.

If the person’s CMDE is more than 36 months old (i.e., three years), the person must receive a new CMDE and meet the medical necessity criteria to restart EIDBI services.