Justifying Medical Necessity

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Writing a Letter of Medical Necessity

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Include the following information:

1. Full 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! Ask the doctor.)

5. Item/service being requested

6. Why the item/service is medically necessary (refer to the insurance plans’ definition)

7. What positive/negative impacts the item/service will result in (include financial)

8. Scope and duration of treatment

9. Supplemental documents (pictures, letters from other providers, research articles, product information, Prior Authorization Request)

10. Include funding streams NOT able to help (denial letters, help)

11. 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

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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?

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The Responsibilities of Each Role

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Care provider needs to:

• Know the process if the parent is not yet skilled

• Know pertinent benefits

• Know limitations and exclusions

• Know the appeals process

• Know terms and their definitions

• Distribute instructive materials to parents (empowerment)

• Write perfect letters of medical necessity

 

Parent needs to:

• Become knowledgeable about the policy

• Supply information to providers

• Keep a paper trail of all communications

• Confront conflicting information

 

Advocate’s role is to:

• Assist with the appeals process

• Guide providers and parents to resources

• Influence systems’ change

 

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Example Letter:

Full name of parent’s

Insurance ID:

Full name of Child: Date of Birth:

Diagnosis codes:

Dear Insurance person: Date:

This letter is to communicate the medical need for a ________________________. My child____________________, has the medical diagnosis requiring this device/service.

I have researched other devices but feel this is the best device for my child. Other devices don’t have

the ability to tilt in space, the __name of device_________________ has this ability, allowing for multiple positions.

Multiple positions are important as _name of child__________must  be repositioned often to reduce

spasticity.  The positions also allow this device to grow with my child. Reducing the need for another device to be purchased in a few years. This device was recommended by a licensed therapist, see attached letter. Without this device my child will require additional therapies and costly surgeries in the future.

I am sure you get letters asking for things every day. I am including a picture of __name of child____________ using this device, to assist you in understanding the importance having this device. If this device is not approved the child will – cost more money, lose mobility, lose community access. I do plan to go through the appeal process if this device is not funded.

Your company’s definition of medical necessity is:

I am communicating that this device for my child fits your definition for the above reason.

Don’t hesitate to call or email if you need additional information, related to this decision.

I look forward to hearing from you.

Sincerely,

Name, ID#

Address

Phone

Email

Attachments:

Doctors, therapist or professional letter

Picture

Marketing material about device

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