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Writing Letters of Medical Necessity

The effectiveness of a funding advocacy/ medical necessity letter can be greatly enhanced if a clinician understands the legal issues involved, pertinent components of a medical necessity letter, and writes the letter in a manner that lays the groundwork for the appeals process if needed.
Before writing the letter, confirm the following:
  • the child is covered by the insurance;
  • the diagnosis is a covered diagnosis (e.g., developmental delay may not be covered); and
  • the item requested is not an exclusion of the policy (e.g. physical therapy).

The components of a medical necessity letter:
  • Identifying Information: child's name, date of birth, insured's name, policy number, group number, medicaid number, physician name, date letter was written.
  • A statement of who you are: the child's primary care physician.
  • The date you last evaluated the patient.
  • The diagnosis of the patient. Think carefully about what diagnoses to include (include as many as possible) as some diagnoses may be an exclusion. One insurance refused to cover Pediasure for a child with a diagnosis of autism because it was an uncovered diagnosis, however, on appeal, they covered the Pediasure for the same child for a diagnosis of chronic constipation, a covered diagnosis.
  • Pertinent medical history (e.g. for a wheelchair approval it would be appropriate to state that the child has cerebral palsy with severe motor impairment).
  • Document pertinent medical, developmental or evaluative information. For the child with poorly controlled asthma for whom you are requesting a nebulizer, you would summarize what treatments have already been in place and how many ER visits and hospital admissions the child has had in the past year.
  • Document why the requested evaluation/treatment/equipment is medically necessary. This is critical to the process but unfortunately, the definition of medically necessary varies from insurance to insurance. Medicaid's definition of being medically necessary is:
    • reasonably calculated to prevent, diagnose, or cure conditions in the patient that endangers life, cause suffering or pain, physical deformity of malfunctions, or threatens to cause a handicap; and
    • there is no equally effective course of treatment available for the recipient which is more conservative or less costly.
  • A summary statement. In this statement try to emphasize the logical conclusion (e.g., A nebulizer is medically necessary for this child with a diagnosis of asthma. Since this insurance covers the diagnosis of asthma and durable medical equipment is a covered benefit, it would be appropriate to approve funding for this child's nebulizer.
  • Signature, professional qualifications and contact information in case the reviewer has questions.
  • Keep a copy of the letter in the patients file. You/the family will need it if you/the family need to file an appeal

Special circumstances:
Equipment request:
  • Indicate which therapist evaluated the child for the requested equipment and refer to the therapist's report or letter.
  • State if the disability is permanent or temporary and how you expect the child's condition to evolve over time.
  • Give a rationale for replacing existing equipment (e.g. he/she has outgrown their current chair and it was determined by the child's physical therapist that the current chair could not be adequately "grown" to meet the child's needs.)
  • Emphasize how the requested item will prevent the onset of secondary disability or increases the individual's function abilities, thus improving the child's overall condition.
  • Avoid referring to caregiver convenience and/or doing "nice" things for the child.
Children with disabilities:
  • Focus on how the service/evaluation/equipment will: prevent the onset of an illness, untoward condition, injury and or secondary disability;
  • Reduce, correct, or ameliorate the physical, mental, developmental, or behavioral effects of an illness, condition, injury, or disability; and/or
  • Assist the individual to achieve or maintain sufficient functional capacity to perform age-appropriate or developmentally appropriate daily activities.

Resources

Information & Support

For Professionals

Sample Letters of Medical Necessity (Dr. Bach)
This site, developed by Dr. John Bach, Professor of Physical Medicine and Rehabilitation and Co-Director of the Jerry Lewis Muscular Dystrophy Association Clinics, offers a variety of sample letters of medical necessity and allows the user to create his/her own letter by filling in the blanks.

How to Write a Letter of Medical Necessity
Rifton is a company that makes equipment for the disabled. Their website offers assistance in writing letters of medical necessity including a checklist and how to deal with the appeals process. The site also has links to pdf sample letters for bathing systems, toileting systems, supine standers, gait trainers, etc.

A Request for a Letter of Medical Necessity(Word Document 27 KB)
A simple, one-page form for parents to fill out that helps the physician write a letter of medical necessity.

A Request for a Letter of Medical Necessity(PDF Document 33 KB)
A simple, one-page form for parents to fill out that helps the physician write a letter of medical necessity.

Insurance preauthorization information (Division of Medical Genetics, UUHSC)(Word Document 46 KB)
Sample letter for family to request pre-authorization for diagnostic tests; in Word.

Insurance preauthorization information (Division of Medical Genetics, UUHSC)(PDF Document 16 KB)
Sample letter for family to request pre-authorization for diagnostic tests; PDF version

Tools

Below you will find sample letters of medical necessity for a variety of conditions and related testing/treatment. These should be adapted to reflect the specifics of your patient and tests/treatment requested. As many of these letters are copies of the original with identifying data deleted, you will notice that several are for more than one test. Letters in Word format may be edited directly with your own demographic information before printing. Some insurance contracts may require a geneticist or other sub-specialist to authorize these tests.

Ltr Ins Preauth – neuropysch testing (Tourette syndrome)(PDF Document 48 KB)

Ltr Med Nec – Beckwith Wiedemann(PDF Document 34 KB)

Ltr Med Nec – CGH, Angelman, Rett(PDF Document 31 KB)

Ltr Med Nec – CGH, underlying syndrome(PDF Document 30 KB)

Ltr Med Nec – Fragile X syndrome, chromosome analysis(PDF Document 52 KB)

Ltr Med Nec – Rett syndrome (MECP2)(PDF Document 56 KB)

Ltr Med Nec – high resolution chromosomes, FISH/Angelman, SmithMag, methylation(PDF Document 30 KB)

Ltr Med Nec – speech therapy(PDF Document 30 KB)

Ltr Med Nec – therapy (generic)(PDF Document 29 KB)

Helpful Articles

O'Brien S, Parker S, Greenberg J, Zuckerman B.
Putting children first: the pediatrician as advocate.
Contemporary Pediatrics. 1997;:103-118.
This article defines the process of advocating for health care funding and gives specific examples of effective and ineffective letters for medicaid funding. It also gives information on how to become active in community advocacy and the legislative process.

Bare J.
Making sense of health plan denials.
Fam Pract Manag. 2001;8(6):39-44. PubMed abstract / Full Text

Authors

Compiled and edited by: Lynne M Kerr, MD, PhD - 10/2008
Content Last Updated: 6/2011