Letters of Medical Necessity

In order to reimburse you for the purchase of equipment or other durable medical goods such as braces, standers, seats, communication aids, toileting aids, and adaptive feeding devices, insurance companies or other funding agencies almost always require a letter of medical necessity from a physician or therapist. Such a letter must include a description of why the equipment was needed, or the request will automatically be denied.

Because the letters written by physicians who are not familiar with insurance company requirements sometimes don’t include all the necessary information, you should be aware of the bare minimum of information that should be in a letter of medical necessity. To help avoid delay or hassle over reimbursement, you can make sure that the physician who writes the letter of medical necessity for you includes all of the information needed by being aware of that information.

The following is an example of a thorough and professional letter of medical necessity. If you like, you can take a copy of this letter to the physician who is writing your child’s letter, and ask that he or she follow the example letter below.

“ To Whom It May Concern (or, better, to a specific employee of the funding agency):

John Smith is a 5-year-old male with a primary diagnoses of cerebral palsy. He was seen at the Seating Clinic at the Alfred I. DuPont Institute in Wilmingtom, Delaware, on June 23, 1993, for the prescription of a new seating system to meet his positioning needs.

John presents with the following: generally decreased tone in upper and lower extremities, and fair head and trunk control. He is dependent in transfers and mobility. He is cognitively severely delayed. He is incontinent in bowel/bladder. He has frequent respiratory complications and is subject to bronchitis and pneumonia, and he receives chest therapy. He occasionally aspirates, he has increased skin sensitivity, and he has seizures, but they’re generally under control with his medication. He must have a tilt-in-space wheelchair with appropriate positioning to provide safety and support, and to facilitate breathing and feeding.

His current seating system is a Zippie tilt-in-space that is three years old. It no longer meets his positioning needs because he has outgrown it, and the seating insert needs to be changed to meet his current positioning needs.

The goals for John for seating are to maintain posture, protect skin, provide comfort, and enhance function. Upon evaluation, the Seating Team has recommended that the following equipment be prescribed for John:

Action Tiger, desk arms, swing away detachable elevating leg rests, semi-reclining back, special seat depth, stroller handles, custom positioners and lateral hip guides, high brackets, solid seat with attaching hardware, solid back with attaching hardware, shoe holders, heavy-duty straps.

The Action Tiger is prescribed because it is a manual wheelchair for total positioning, and because he is dependent in mobility. The tilt is needed because he is hypotonic in head and trunk. He also has difficulty breathing, and it will help aid in feeding. It will help with low endurance and pressure relief, and it will control seizure reaction. The adjustable height arms are needed to support tray at right height, for upper body support and balance, and for ease of transfers. The I-back will bring side supports close to trunk, but insert will fit the full width of the wheelchair. The laterals will encourage midline trunk position, compensate for lack of trunk control, provide safety, and contour around trunk for better control. The chest harness is needed for safety in transport by providing anterior support, preventing forward flexion, and retracting shoulders. The headrest is needed for poor head control due to low tone, active flexion of head, posterior lateral support, safety in transfers, and to facilitate breathing. The clear tray is needed for functional surface for schoolwork, stimulation, upper arm and trunk support, inability to access tables, computer, and a base for augmentative communication devices. The shoe holders are needed to control increased extension or spasms in lower extremities, excessive internal rotation, and to prevent aggressive behavior for safety. The anti-tippers are needed for safety.

Should you have any questions regarding these recommendations, please do not hesitate to call me at (302) 555-5850. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistence in this manner.

Sincerely,
Freeman Miller, M.D.
Pediatric Orthopedic Surgeon”

Make a note of the date the letter was mailed, and if after three or four weeks you haven’t heard anything, it might be a good idea to call the insurance company or funding agency and gently inquire about the status of the claim. Make sure to find out the name of the person you speak to, and write it down. The person will probably tell you that the claim is being processed; you can ask when you might expect to receive notification of payment, and then call again if that date passes and you still haven’t heard anything. It’s generally not a good idea to be seen as a nuisance or worse, as an irate client. You do want to stay on top of the situation, however, and let the agency know that you are doing so. If the agency remain unresponsive, you can always enlist your doctor’s assitance.

Related Links

Sample Letters of Medical Necessity

Rifton Equipment: How to Write Letters of Medical Necessity

Letters of Medical Necessity: What Providers Need to Know!

Technical Assistance Project: What Should Be in a Letter of Medical Necessity?

Enbrel.com: Useful Forms: Sample Letters of Medical Necessity

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