Helping you stay healthy
Justifying Medical Necessity
Writing a Letter of Medical Necessity
Include the following information:
Full name of child, names of parents (parents and child may have different names)
Date of birth of child
Insurance plan name (there may be more than one plan)
Relevant diagnoses (codes are helpful only if they are accurate! Ask the doctor.)
Item/service being requested
Why the item/service is medically necessary (refer to the insurance plans’ definition)
What positive/negative impacts the item/service will result in (include financial)
Scope and duration of treatment
Supplemental documents (pictures, letters from other providers, research articles, product information, Prior Authorization Request)
Include funding streams NOT able to help (denial letters, help)
Terms to use:
preventing secondary disability
Terms to avoid:
speech delay (without a diagnosis such as aphasia)
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
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
Full name of parent’s
Full name of Child: Date of Birth:
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.
Doctors, therapist or professional letter
Marketing material about device
Example of a Seizure Action Plan
Emergency Contact: Phone:
Name_______________'s MEDICAL History:
Patient, has a history of seizures, displayed by for Seconds/minutes.
If has a seizure lasting longer than minutes:
Call: parent: name: phone:
Call 911 if seizure lasts longer than 5 minutes and no rescue medications are available.