- The child is covered by the insurance.
- The diagnosis is a covered diagnosis (e.g., developmental delay may not be covered).
- 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, and 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, causes suffering or pain, physical deformity or 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 patient's file. You/the family will need it if you/the family need
to file an appeal.
- 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., the child 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 functional abilities, thus improving the child's overall condition.
- Avoid referring to caregiver convenience and/or doing "nice" things for the child.
- 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.
Sample Letters of Medical Necessity (Dr. Bach)
Offers sample letters of medical necessity and allows users to create their own letter by filling in the blanks; developed by Dr. John Bach, Professor of Physical Medicine and Rehabilitation and Co-Director of the Jerry Lewis Muscular Dystrophy Association Clinics.
Examples of Letters of Medical Necessity (Rifton)
Offers downloadable examples of letters of medical necessity as well as equipment-specific letters, such as bathing systems, toileting systems, supine standers, and gait trainers). (Although geared toward Rifton-made equipment, the letters may be adapted.); Rifton is a commercial manufacturer of equipment for the disabled.
Request for a Letter of Medical Necessity Form (Portal) ( 27 KB)
A simple, one-page, downloadable form in Word for parents to fill out as a way to help the clinician write a letter of medical necessity; created by the Medical Home Portal.
Insurance Preauthorization for Diagnostic Test Form (University of Utah) ( 46 KB)
Sample letter in Word that can be downloaded when a family is requesting pre-authorization of diagnostic testing; Division of Medical Genetics, University of Utah Medical Center.
O'Brien S, Parker S, Greenberg J, Zuckerman B.
Putting children first: the pediatrician as advocate.
Contemporary Pediatrics. 1997;:103-118.
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.
|Compiled and edited by:||Lynne M Kerr, MD, PhD - 10/2008|
|Content Last Updated:||6/2011|