Writing a Letter of Medical Necessity

1. Name of child, names of parents (parents and child may have different names)
2. Date of birth of child
3. Insurance plan name (there may be more than one plan)
4. Relevant diagnoses (codes are helpful only if they are accurate!)
5. Item/service requested
6. Why item/service is medically necessary (refer to the plans’ definition)
7. What positive/negative impacts the item/service will result on (include financial) scope and duration of treatment
8. Supplemental documents (letters from other providers, research articles, product information, PAR)
9. Include funding streams NOT able to help (denial letters help)

Terms to use; medically necessary, clinically based, promoting independence, preventing secondary disability, cost-effective, safety.

Terms to avoid; custodial, rehabilitate, developmental delay/disability, speech delay (without a diagnosis such as aphasia), Caregiver convenience.

10. Ask if your Letter of Medical Necessity answers the following:
    • Is there a licensed provider stating in writing the item/service is medically necessary?
    • Is this item/service not for care giver convenience?
    • Is this item/service costs effective and if so have you explained how?
    • Is this item/service considered standard medical practice?
    • Have you explained how long and how often the item/service will be used.
    • Is this item/service right for the need of individual?

The Responsibilities of Each Role

Care provider needs to know the process if the parent is not yet skilled

1. 1. pertinent benefits
   2. limitations and exclusions
   3. appeals process
   4. terms and their definitions
   5. distribute instructive materials to parents (empowerment)
   6. write perfect letters of medical necessity

Parent needs to

1. 1. become knowledgeable about the policy (a-d above)
   2. supply information to providers
   3. keep a paper trail of all communications
   4. confront conflicting information

Advocate’s role is to

1. assist with the appeals process
2. guide providers and parents to resources
3. influence systems’ change

Health insurance plan’s staff member

1. 1. confuse the member as much as possible (i.e., change the rules often), and deny benefits to contain costs.