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Medical Necessity

By: Cristina Martínez M.B.A, M.S, BCBA, LBA Coauthor: Ariadna Martin MS

Medical necessity is a fundamental concept that permeates our professional practice. Applied Behavior Analysis (ABA) therapy, a vital component of healthcare services, offers a therapeutic option that directly addresses the medical needs of the individuals who receive it. This approach underscores the importance of ABA in contributing to significant health outcomes.

In general terms, Medical Necessity refers to the principle that healthcare services, procedures, treatments, or supplies provided to a client must be deemed essential and appropriate for the diagnosis or treatment of their medical condition. It's a fundamental concept in healthcare decision-making, ensuring that interventions are justified by clinical need and evidence-based medicine rather than convenience or preference. Determining medical necessity involves evaluating factors such as the client’s medical history, symptoms, test results, and the standards of care established by medical experts. This principle guides not only healthcare professionals, but also insurers in making decisions about coverage, reimbursement, and the allocation of resources to optimize client outcomes while managing costs effectively.

Focusing once again on our professional field, medical necessity refers to the determination that the treatment is essential for addressing a diagnosed condition or disorder. Establishing the medical necessity of ABA therapy involves a comprehensive assessment of the individual's needs and a determination that the treatment is both clinically appropriate and effective for addressing those needs. Basically, each step of the process is guided by the connection of the medical necessity with the actions to be taken:

  1. Diagnosis: A qualified healthcare professional, such as a psychiatrist or psychologist, diagnoses the individual with a condition that may benefit from ABA therapy, such as Autism Spectrum Disorder (ASD).
  2. Assessment: An assessment is conducted to evaluate the individual's specific needs, strengths, behavior functions, and challenges. This assessment may include behavioral observations, standardized tests, interviews with caregivers, and other evaluations.
  3. Treatment Plan: Based on the diagnosis and assessment, a treatment plan is developed that outlines the goals of ABA therapy and the specific interventions to be implemented.
  4. Documentation: Documentation is prepared to support the medical necessity of ABA therapy. This may include the diagnosis, assessment results, treatment plan, and any other relevant medical records.
  5. Review: The documentation is reviewed by healthcare professionals, insurers, or other relevant entities to determine whether ABA therapy is medically necessary for the individual.
  6. Authorization: If ABA therapy is deemed medically necessary, authorization may be obtained from insurers or other payers to cover the cost of treatment.
  7. Monitoring and Review: The individual's progress in ABA therapy is monitored over time, and the medical necessity of ongoing treatment is periodically reviewed to ensure that it continues to be appropriate and beneficial.

Medical necessity, in other words, is the condition that brings meaning and direction to therapy. That is why, in regulatory terms, it is required and rigorously evaluated. At American Behavioral Solutions, we are deeply committed to the quality of the services we provide, so we incorporate the evaluation of medical necessity in our practice, as a crucial element to obtaining the best results.

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