Letter of medical necessity 2024 (guide + free template)

A Letter of Medical Necessity or medical necessity letter is a document written by a healthcare provider that explains why a specific medical treatment or service is necessary for a patient.

This letter provides information about the patient’s medical condition and why the recommended treatment is the most appropriate and effective option available.

It serves as a JUSTIFICATION for why a particular medical intervention is required for the patient’s health and well-being.

Let me tell you this;

I have seen so many times that Insurance companies frequently deny medical claims citing “lack of medical necessity” as a common reason.

That also happened to one of my friends;

His insurance provider denied covering his surgery cost stating that it was not medically necessary.

What we did to overcome that challenge was to appeal against their decision and attach a strong letter of medical necessity from an expert that detailed why my friend’s surgery was medically necessary.”.

That made me remember the words of Feldman, Joseph MBA et.al n their Journal Titled Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients, that;

A medical necessity letter can be an essential tool in patients’ dealings with insurers, empowering patients to preempt or reverse insurance denials by reinforcing the basis of case-specific clinical decisions and establishing the clinician’s assessment of the treatment as “medically necessary.”

Therefore, to help you get the most out of the medical necessity letter here I will guide you through the following;

• What is a letter of medical necessity?
• Why do you need a letter of medical necessity?
• How to get a letter of medical necessity
• What should a letter of medical necessity contain?
• letter of medical necessity template
• letter of medical necessity example
• etc.

What is a letter of medical necessity?

A letter of medical necessity or medical necessity letter is a brief statement of facts written by a medical provider to provide detailed information about your medical condition and why a particular treatment or service is necessary for your health.

You can use this letter to support a request for coverage or reimbursement for a medical service or treatment.

Or,

You may use this letter in situations where your insurance company is questioning the need for a particular procedure or treatment,

Or

When you are seeking coverage for a service that is not typically covered by your insurance plan.

To be effective, a medical necessity letter must provide clear and specific information about your medical condition and the reasons why a certain treatment is necessary for you.

In addition to that, this letter may also include information about the previous treatments that you have received and their effectiveness, as well as any other relevant medical information.

Key Takeaway: A letter of medical necessity is a key document that can help you get coverage or reimbursement for important medical services or treatments.

What does it mean to be medically necessary?

Before going any further, I think it is important to tell you what it means to be medically necessary.

Well!

Being medically necessary means that a specific medical treatment or device is necessary to diagnose, prevent, or treat your illness or injury.

In other words, the treatment or device is considered essential for maintaining your health or improving your condition.

The determination of medical necessity is typically made by a healthcare provider, who will consider factors such as your medical history, current condition, and potential risks and benefits of the treatment or device.

In some cases, a healthcare provider may consult with other medical experts or refer to established medical guidelines to determine whether your treatment or device is medically necessary.

Key Takeaway: Medically necessary means that a certain medical treatment or procedure is necessary to save your life.

How to get a letter of medical necessity

Getting a well-written letter of medical necessity is not that hard;

Just ask a doctor who has treated or examined you.

Your doctor will be able to provide you with a letter that includes detailed information about your medical condition and why a particular treatment or service is necessary for your health.

Here is how we obtained a letter of medical necessity for my friend’s surgery

1. We contacted the doctor who examined him and explain that we need a letter of medical necessity.
2. We scheduled an appointment to discuss important issues;
3. During the appointment, we discussed his medical condition and the reasons why the requested treatment is necessary. The doctor asked questions and gather information about my friend’s health and medical history.
4. After the discussion, the Doctor came up with a strong letter that includes detailed information about my friend’s medical condition and the reasons why the treatment is necessary.

Key Takeaway: to get a well-written letter of medical necessity, all you need to do is ask a doctor who has treated or examined you.

What should a letter of medical necessity contain?

A letter of medical necessity should contain detailed information about a person’s medical condition and why a particular treatment or service is necessary for their health.

The following must not miss;

1. The person’s name and contact information
2. The date the letter was written
3. The name and contact information of the healthcare provider who wrote the letter
4. A detailed description of the person’s medical condition, including any relevant diagnostic tests or procedures
5. A description of the treatment or service being requested, including the specific medical code if applicable
6. A clear explanation of why the treatment or service is necessary, including any potential risks or benefits
7. Information about any previous treatments that have been tried and their effectiveness
8. Any other relevant medical information that may support the request for coverage or reimbursement.

I will reinforce my points by referring you back to the Feldman, Joseph MBA et al. Journal.

In their journal Feldman, Joseph MBA et.al provided the 4 key elements in an effective medical necessity letter; (emphasis is mine)

1. a statement of medical provider credentials
2. a description of provider practice, including his level of experience and expertise in treating people with specific conditions.
3. a clinical assessment of the patient, especially unique aspects of the patient’s presentation, history, or living circumstances
4. most importantly, an explanation as to why the course of treatment is “medically necessary,” including the rationale (clinical decision-making process) justifying that treatment.

Apart from what to include in your letter, how you write your letter is also important.

Write your letter in a professional and concise manner.

Make sure it is clear and specific.

Key Takeaway: A letter of medical necessity must contain all relevant information to prove that a certain medical treatment is medically necessary.

Letter of medical necessity template

The following is a general template of a medical necessity letter

MEDICAL PROVIDER LETTERHEAD

DATE

Recipient Name
Position
Department
Insurer Company Name
Street address
City, State Zip Code

Re: [Patient name]

DOB: [Insert Patient’s Date of Birth]
Policy Number: [Insert Patient Policy Number]
Claim Number: [Insert Patient Claim Number]

Dear Mr./Mrs./Ms. [Recipent’s last name]

This is to document the medical necessity to treat [name of patient] for [diagnosis] with [product/service name]

This letter summarizes the patient’s medical history and diagnosis, as well as the treatment plan.

Patient’s Medical History and Diagnosis

[Patient Name] is [Age] years old and was initially identified as having [Diagnosis] [ICD-10-CM] on [Date]. I’ve been taking care of [Patient Name] since [Date], here is his/her diagnosis and medical history.

[Provide a brief explanation of the benefits of [DRUG NAME] therapy. This includes a brief explanation of the patient’s diagnosis, including the ICD-10-CM code, the seriousness of the patient’s condition, any prior treatments, the length of each, the results of those treatments, the justification for discontinuation, as well as any additional factors (like underlying health conditions or age) that may have affected your choice of treatment.]

Treatment plan

[Include the treatment plan (dosage, duration of treatment), as well as any clinical practice recommendations that support the use of the product/service. Think about mentioning specialists who agree with the treatment.]

Rationale for Treatment

[Include your clinical rationale and reasons for prescribing the product]

Based on the facts stated above, I am confident that [Product Name/Service] is medically necessary and reasonable for the treatment of [Patient Name’s] [Diagnosis], and I humbly request that you consider coverage of [Product name/service] on [Patient Name’s] behalf.

Kindly see the enclosed supporting documents for more information and contact me at [Phone Number] if you have any questions or need additional information.

Thank you for your understanding regarding this matter.

Sincerely,
[Physician Name and Credentials]

Enclosures

[List enclosures, which may include: prescribing information, clinical notes/medical records, diagnostic test results, relevant peer-reviewed articles, FDA approval letter, scans showing progressive disease, and pathology reports.]

Simple letter of medical necessity (template)

The following is a simple template of a medical necessity letter to an insurance company to support a patient’s medical claim.

Dear Mr./Mrs./Ms. [Recipent’s last name]

I am writing to request coverage for [Patient Name] for [Treatment or Device]. This treatment/device is medically necessary for the following reasons:

[Explanation of medical necessity, including details of the patient’s condition and how the treatment/device will help]

[Patient Name] has been under my care for [length of time]. I have tried [other treatments/devices] but they have not been effective. [Treatment or Device] is the only option that is likely to improve [Patient Name]’s condition.

I am confident that [Treatment or Device] is necessary for [Patient Name]’s health and well-being. I strongly recommend that it be covered by [Insurance Company].

Sincerely,
[Healthcare Provider]

Letter of medical necessity pdf

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