2 EXAMPLES of LETTER OF MEDICAL NECESSITY
The following example letter of medical necessity and advice are only intended to assist you in writing your own letter to aid in securing funding for medical equipment. It is in no way implied that if you use this example you will be granted funding for medical equipment. Our only intention is to share information that we have gathered in the past and used by other clients.
The funding agencies that would be in charge of compensation for such medical items, such as your insurance company or a private philanthropic organization, almost always demand a letter of medical necessity from a therapist (physical, occupational, or otherwise) or from a physician to prove your claim that your child’s medical equipment was necessary to his successful treatment. The claim or appeal will be likely be refused if you do not include a letter of medical necessity which includes a detailed explanation of the condition or disability that makes the equipment a necessity for your loved one.
It is possible that your particular physician may not fully be acquainted with the rules of your insurance company which will affect whether or not you are reimbursed for your child’s medical equipment. (Each insurance company or state may have slightly different rules.) To be on the safe side, educate yourself on the rules so that you can be a better advocate for your family. You should become familiar with the bare minimum of information that needs to be included in a letter of medical necessity. Otherwise, the letter may contain insufficient information, which may lead to the funding agency denying your claim.
The following is an example of a thorough and professional letter of medical necessity taken from Dr. Freeman Miller’s Cerebral Palsy: A Complete Guide for Care giving. If you prefer, you can take a copy of this letter to the physician who is writing your child’s letter of medical necessity, and ask that he or she adhere to 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 diagnosis of cerebral palsy. He was seen at the Seating Clinic at the John Doe Institute in Anywhere, USA, on June 23, 2007, for the prescription of a bed system to meet his resting 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 safe sleeping environment to eliminate the danger of falls and entrapment with appropriate positioning to provide safety and support, and to facilitate safe sleeping, breathing and feeding.
His current bed is a ___________ that is three years old. It no longer meets his bedding needs because he has outgrown it, and it poses safety concerns because_____________________.
The goals for John’s sleeping and resting is to provide a safe sleeping environment where falls and entrapment no longer pose a threat for harm and to foster a comfortable rest, maintain posture, provide comfort, and enhance function. Upon evaluation, _____________________ has recommended that the following equipment be prescribed for John:
(Be very specific in the bed model, size, and specific safety features)
the following example is for a wheel chair…rewrite this section to detail all of the specific features of the recommended bed system….for example…the Sleep Safe 2 Plus model is prescribed because it offers 22 inches of safety rail height protection above the mattress, eliminating the risk of a fall when he is in a sitting position. The “plus” model frame is prescribed because he is dependant on tube feedings and his head must be elevated during this time….etc)
The ____________________(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 (555) 555-5555. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistance in this manner.
Be sure to take note of when your child’s letter was sent to the funding agency, and if three or four weeks pass without word from them, you might want to call the agency to inquire about the status of your claim. Always keep a record of when you call and with whom you speak to, and always try to remain calm and collected when dealing with the insurance company. If, however, you are unable to obtain a straightforward response as to when your claim will be processed, do not hesitate to enlist the help of your physician.