Letter of medical necessity 2023 (guide + free template)

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This post covers everything you need to know about letter of medical necessity or medical necessity letter.

Lack of “medical necessity,” is a common reason given by insurance companies to deny your medical claim.

To overcome that challenge you need a strong letter of medical necessity from your medical provider to prove to the insurer that the treatment received is/was medically necessary.

In their Journal Titled Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients, Feldman, Joseph MBA et.al stated 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.”

Feldman, Joseph MBA; DeBofsky, Mark JD; Plakun, Eric M. MD; Potts, Cheryl MBA. Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients. Journal of Psychiatric Practice: July 2021 – Volume 27 – Issue 4 – p 288-295
doi: 10.1097/PRA.0000000000000563

Read:

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 a person’s medical condition and why a particular treatment or service is necessary for their health.

This letter is often used to support a request for coverage or reimbursement for a medical service or treatment.

It may be used 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 their insurance plan.

A medical necessity letter should provide clear and specific information about the person’s medical condition and the reasons why the requested treatment is necessary.

It may also include information about any previous treatments that have been tried and their effectiveness, as well as any other relevant medical information.

What does it mean to be medically necessary?

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

Insurance companies often use the concept of medical necessity to determine whether to cover a specific treatment or device.

In these cases, a letter of medical necessity from a healthcare provider may be required to provide evidence that the treatment or device is necessary for the patient’s health and well-being.

Why do you need a letter of medical necessity?

You may need a letter of medical necessity from your medical provider if;

  • Your insurance provider denies the need for a specific medical treatment or service.
  • You’re trying to get coverage for a service that isn’t typically covered by your insurance plan

In these circumstances, a letter of medical necessity can offer your insurer crucial details about your health condition and the justifications for the requested treatment.

Having a letter of medical necessity can help support your request for coverage or reimbursement for a medical service or treatment and help your insurer to make a more informed decision.

How to get a letter of medical necessity

To get a letter of medical necessity, you should speak with your healthcare provider who has treated or examined you.

Your provider 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.

To request a letter of medical necessity from your provider, you can do the following:

  1. Contact your provider’s office and explain that you need a letter of medical necessity.
  2. Schedule an appointment with your provider to discuss your medical condition and the treatment or service that you are requesting.
  3. During the appointment, discuss your medical condition and the reasons why the requested treatment is necessary. Your provider will ask you questions and gather information about your health and medical history.
  4. After the appointment, your provider will write a letter of medical necessity that includes detailed information about your medical condition and the reasons why the treatment is necessary.
  5. Once the letter is written, you can either pick it up from your provider’s office or have it sent to you by mail or email.

Who can write a letter of medical necessity

A letter of medical necessity can be written by a healthcare provider, such as a doctor, nurse practitioner, or physician assistant.

The healthcare provider should have knowledge of the patient’s medical condition and be familiar with the treatment or device that is being requested.

In some cases, the letter may also be written by a healthcare administrator or other staff member who has knowledge of the patient’s medical history and treatment plan.

It is important that the person writing the medical necessity letter is able to provide detailed information about the patient’s condition and the need for the requested treatment or device.

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 letter should include specific information about the person’s medical history and current condition, as well as the reasons why the requested treatment is necessary.

In general, a letter of medical necessity should include the following information:

  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.

To cement that, in their Journal as referenced above, Feldman, Joseph MBA et.al provided the following 4 key elements in an effective medical necessity letter;

emphasizes are 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.

It’s important for a letter of medical necessity to be clear and specific in order to provide the necessary information to support a request for coverage or reimbursement.

The medical necessity letter should be written in a professional and concise manner and should be easy for the reader to understand.

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

Read also: Medical referral letter (guide + free template)

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Isack Kimaro
Isack Kimaro

Holder of Bachelor of Laws (LL.B) and Post Graduate Diploma in Legal Practice. I am dedicated to providing valuable and easy-to-understand legal information for individuals at all levels of understanding. Whether you are a layperson looking to increase your knowledge, a law student striving to excel in your studies, or a practicing lawyer wanting to expand your expertise, I am here to help. I'm not creating content, I'm creating awareness to empower you to take control of your legal understanding and achieve your goals.