Guide to a Letter of Medical Necessity for ABA Therapy

Applied behavior analysis (ABA therapy) is considered the leading treatment for children with autism spectrum disorder (ASD). This is why a prescription for ABA therapy often follows an ASD diagnosis.

Luckily, awareness, understanding and acceptance of individuals with autism has increased substantially in recent years, and that has led many states to pass legislation requiring insurance companies to cover autism-related services, including ABA therapy.

This is obviously great news for individuals with autism and their families. Even still, most insurance companies require documentation and verification that ABA therapy is necessary before they will cover it, as ABA therapy can be quite intensive and, as a result, costly.

While the requirements you must meet can vary from one insurance company to the next, most will require what’s known as a letter of medical necessity for ABA therapy.

In this article, we’ll discuss this topic in more detail, helping you understand what a letter of medical necessity for ABA therapy is and how to get one.

Key Takeaways

A letter of medical necessity is essential for insurance coverage of ABA therapy.
The letter must include diagnosis, symptoms, recommended hours, setting, and provider details.
Only qualified medical professionals (often with support from BCBAs) can write and/or sign the letter.
Blue Gems ABA collaborates with families and professionals to ensure accurate and compliant documentation.
The letter also serves as a comprehensive overview of the child’s diagnosis and care plan.

Table Of Contents

What a Letter of Medical Necessity for ABA Therapy Is

A letter of medical necessity for ABA therapy is a comprehensive document that is meant to explain why ABA therapy is necessary and appropriate for a child’s overall well-being. While these letters are often meant for insurance companies, they can also be relevant for other organizations.

Contained in the letter of medical necessity will be an explanation of why ABA therapy is justified. This will be based on the individual’s specific diagnosis as well as scientific evidence to show that ABA therapy is the most effective treatment method.

The letter will often outline the specific symptoms that your child is experiencing, potentially the severity of those symptoms, and how ABA therapy can address them. It will also often include what the professional based their diagnosis on.

The nice part about letters of medical necessity for ABA therapy is that they will also serve as a transparent guide to your child’s diagnosis and care, and can be used for many other things in their treatment and support.

Challenge	How ABA Therapy & Letters of Medical Necessity Address It
Insurance won’t cover ABA therapy without proof	Letter of medical necessity provides required documentation and justification
Uncertainty about what information to include	Template includes diagnosis, symptoms, therapy details, session duration, and setting
Not knowing who should write or sign the letter	Qualified professionals (e.g., pediatricians, psychiatrists) with support from BCBAs can write and/or sign
Lack of clarity about treatment goals	Letter outlines benefits and objectives of ABA therapy tailored to the child’s diagnosis

What Does a Letter of Medical Necessity for ABA Therapy Have to Include?

Each state, insurance company and/or insurance policy may require different things to be contained in a letter of medical necessity for ABA therapy. Most must contain at least the following basic details …

Patient’s basic information, such as name, birthdate and medical history
Information on the medical provider
Patient’s diagnoses and the specific symptoms they are experiencing
Details of what ABA therapy is, a clear recommendation for it and the benefits the patient is likely to receive from it
Recommendation for hours of ABA therapy every week and how long the services should last per session
Explanation of where the ABA therapy should occur, such as a breakdown of hours for therapy at home, in school or at a clinic

Who Must Write the Letter of Medical Necessity?

The signatory of the letter often must be a professional who’s qualified to give an ASD diagnosis and a subsequent recommendation of ABA therapy. This can be a pediatrician, clinical psychiatrist or neurologist, for example.

This professional should also have seen your child in the last six months when they write the letter.

Sometimes, the letter will also be written and/or signed by a Board Certified Behavior Analyst (BCBA), who either works with the medical professional or works for an ABA therapy company.

The letter can be written by the medical professional and then signed by them and a BCBA; it can be written by BCBA and signed by the medical professional; or it can be done in a collaborative way.

Regardless of who writes it, it’s important that the medical professional provide their signature on the document, as well as a concurring statement to anything the BCBA has written. This is something that many insurance companies require to be included in a letter of medical necessity for ABA therapy.

Blue Gems ABA Can Help Prepare Letters of Medical Necessity for ABA Therapy

Insurance companies often require a letter of medical necessity for ABA therapy before they will cover the services. Understanding what these letters are, what they must include and who must write them is essential to streamlining your child’s necessary services.

At Blue Gems ABA, our team of experienced BCBAs work in a collaborative way with parents, caregivers and other medical professionals to provide the best care possible for children with ASD. This includes helping prepare letters of medical necessity for ABA therapy so your child’s treatment can get covered.

To learn more, please contact us today.

Frequently Asked Questions

Q: Who can write a letter of medical necessity for ABA therapy?
A licensed professional such as a pediatrician, psychiatrist, or neurologist — often in collaboration with a BCBA.
Q: What information should the letter include?
Diagnosis, symptoms, therapy recommendation, hours per week, session length, and location of services.
Q: Can a BCBA sign the letter alone?
No. Most insurers require the signature of a licensed medical provider, even if the BCBA contributes to the writing.
Q: Is the letter only for insurance purposes?
No. It can also support access to other services and serve as a transparent care guide.