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Special Services Home > Medicaid > Medical Necessity decision tree

Updated 01/25/2011...wl

“Medical Necessity” decision tree

The following is a guide to determining whether a service on a child’s IEP is billable to MaineCare, which requires the service to be medically necessary.  This tool is not designed to determine what services a student needs, but only whether the services are reimbursable by MaineCare.  A simple explanation is:
To meet the Medicaid standard for Medical Necessity, any one of the three standards below can be met:

  • The service or benefit will, or is reasonably expected to, prevent the onset of an illness condition, or disability
  • The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition or disability.
  • The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

Therefore, the questions that need to be addressed are:

  1. Does the student have a diagnosis of a medical condition/intellectual impairment/behavioral health condition from a physician or other qualified health care provider licensed to make that diagnosis?
    (This refers to a medical diagnosis described by either a DSM-IV or ICD-9 code that is provided by a physician, practitioner of the healing arts (for instance an occupational therapist, physical therapist of speech pathologist) or mental health professional licensed to make diagnoses (these include psychologists, LCSWs, LCPCs, or LMFTs).

If yes, continue.

  1. Does the diagnosed condition result in a significant impairment of cognition, function or behavior?
    (Significant, in this context, has the same meaning as educators apply when determining whether a student’s disability adversely impacts their education.  A slight impact does not qualify a student for special education services and a slight impairment of cognition, function or behavior does not qualify a student for MaineCare services.  The eligibility criteria for each service can be found in the section describing the billable service and the practitioner of the healing arts is responsible for knowing what those criteria are.)

If yes, continue.

  1. Do the proposed services constitute medical treatment and not primarily educational services to correct or ameliorate the diagnosed condition? 
    (An example of this distinction is as follows:  If a student needs a 1:1 to assist with that student’s progress in learning math, that 1:1 is performing an educational service.  If, on the other hand, the 1:1 is needed to help that student manage his/her behavior while learning math, the 1:1 is performing a medically necessary service related to that student’s behavioral disregulation.  Just because a service is medically necessary does not mean that the service is not also educationally necessary, but the focus for a medically necessary service is on the management/treatment of the underlying medical diagnosis.)

If yes, please specify how.

  1. Are the proposed services described in the MaineCare Benefits Manual?
    (The services for which a school can bill are OT, PT, Speech, day treatment and early intervention services.  One-on-one services can be billed if provided by a Behavioral Health Professional (BHP) or a licensed Masters-level clinician (LCSW, LMSW-CC, LCPC, or LMFT) in conjunction with day treatment services.)

If you have answered yes to all of the above and are able to specify how the service corrects or ameliorates the student’s condition, the service is medically necessary. 

Please see below for the definition of medical necessity from Chapter 1 of the MaineCare Benefits Manual.

Medical Necessity or Medically Necessary services are those reasonably necessary medical and remedial services that are:

  1. provided in an appropriate setting;
  2. recognized as standard medical care, based on national standards for best practices and safe, effective, quality care;
  3. required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being;
  4. MaineCare covered services (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter II, Section 94 of this Manual);
  5. performed by enrolled providers within their scope of licensure and/or certification; and
  6. provided within the regulations of this Manual.