A letter of medical necessity is a document that is usually issued by a medical professional on behalf of a patient seeking reimbursement for a medical procedure. They are very common for medical procedures that are not covered under standard health care plans, so it is necessary for a special request to be made. The recipients of these letters are usually health insurance companies or health care provision companies.
State the patient’s background and outline their condition.
For something to be deemed a medical necessity it has to either help diagnose or treat an illness or injury, or improve physical function. It is therefore important to explain how the proposal meets these aims.
Be careful to describe the procedure as a treatment that improves health, not an enhancement to normal standards of health. If not adequately explained, procedures like speech therapy can be rejected as they are not deemed a necessity.
Make it clear that this is the only procedure that suits the patient’s needs.
Be formal and polite. This is a request, not a demand.
To Whom It May Concern:
Janine Baker has recently been diagnosed with a rare form of lung disease, which causes great difficulty breathing and respiratory problems for the patient. The symptoms have gotten progressively worse, to the point where they are beginning to affect the lifestyle that Janine can live.
Janine has taken part in many different medical procedures, but they have not been successful in remedying the problem. There is a new technology that can be used to combat this disease, but it is currently not covered under Janine’s healthcare program.
Please consider coverage for this new disease prevention technology for Janine. If you would like additional information and potential costs for this procedure, don’t hesitate to contact me at 342-234-2343
Dear Sir or Madman,
My patient Mr. Shaun Lesley has suffered from hearing loss for five years after loud machinery damaged his inner ear at work. Though he can hear moderately well with a digital hearing aid, most sounds are still quiet and distorted to him.
Over time this has caused his speech to suffer, as what one says is inextricably linked to what one hears from others and themselves. His condition has resulted in poorly pronounced words, slurring, and inappropriate tones and pitches.
I am writing to request authorization for speech therapy to be covered by his insurance. His condition represents clear diminished function in his ability to speak and interact with others, and therefore falls within the scope of medical necessity.
Mr. Lesley was diagnosed with hearing loss induced expressive aphasia, by a speech-language pathologist on June 05, 2011. The recommended treatment is regular sessions of traditional speech therapy, involving guided pronunciation of words via repetition. We will teach Mr. Lesley to recognize the sound of properly formed words, so he will be more competent when he speaks.
Thank you for your consideration in this matter.
To whomsoever it may concern,
I am writing to request that my child patient Laurence Holwell, be granted coverage for the use of an orthotic device to correct a poorly developed bone in his left ankle, that over time will impede his ability to walk correctly and eventually cause a noticeable limp.
I feel that this appliance that will be fitted in footwear is a medical necessity, for the prevention of a serious long term disability. Because the child is 6 years old surgery is not necessary, but if left until the early teen years will be a costly and invasive procedure.
The plastic polymer device is inserted within the child’s shoe, which over time will force the ankle to grow back in to the normal direction. Each device costs $100 to produce and will be needed for four years. Due to changes in shoe size over this time, I estimate the need for at least 5 of these devices.
I hope you can appreciate that this is not an enhancement or convenience, but a medical necessity for my patient’s long term wellbeing.
If you require any further information I can be contacted on (575) 962-2984.
Dear Alonso Medical,
I am writing to inform you that my patient of 10 years, Mrs. Bunting, who is covered by your medical insurance, was recently the victim of a fall at work and has a partially slipped disc in her back.
I have determined that surgery is not necessary so long as she’s covered for sessions of physical therapy, including guided mobility exercises to maintain range of motion, and deep tissue massage to ensure full flexibility. Over a four week period this will gradually ease the disc back in to place.
Failure to carry out these procedures will result in immobilizing sciatica, that will need costly surgery to correct.
Thank you for your understanding.
Pikes Ridge Medical Practice
To Whom It May Concern,
My 70 year old patient Dwight Morgan is suffering from severe arthritis of the legs and has just been diagnosed with spinal cancer. He is also weak throughout the body.
He immediately requires the assistance of an electric wheelchair to maintain any semblance of independence, as he goes through a period of extremely tough treatments.
I believe the use of a wheelchair to be a clear medical necessity that will prolong his life. Failure to stay active will compound his deterioration.
I trust you agree and will proceed to cover Mr. Morgan for this last remaining comfort.
Velvet Village Surgery
Dear Sir or Madam,
My patient of 20 years, Mr. Jeff Delacey, is in dire need of bariatric surgery to reduce his weight and prevent several serious health problems, each in early stages of development.
Mr. Delacey is 6ft 5 and weighs 400 lbs, however this is not your typical case of obesity. My patient has been confined to a wheelchair since the age of 5, due to partial paralysis following a car accident. Due to the limitations of physical exercise and clinical depression, he has found it extremely difficult to maintain a manageable level of weight.
I suggest that gastric band surgery is necessary to prevent diabetes and heart disease, which are already in their early stages. At 26 years old I feel he can return to an accepted level of health and prevent many of the cardiovascular risks associated with older patients of his predicament.
I hope you agree that this is an important procedure that should be covered by his insurance.
If you require any further information, please do not hesitate to contact the surgery.
Gentle Lake Healthcare