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    Sample Letter of Medical Necessity

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    Min Soe
    This document provides a sample letter of medical necessity that can be customized for a patient. The letter is intended to explain the physician's rationale for choosing a specific therapy and help obtain prior authorization or coverage from a health insurance payer. It includes fillable fields for the patient's information, diagnosis, medical history, previous treatments tried, and the physician's recommendation and plan for the requested treatment. The letter aims to document that the therapy is medically necessary for the patient.

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    Download as PDF, TXT or read online from Scribd

    Sample Letter of Medical Necessity

    Uploaded by

    Min Soe
    402 views2 pages
    This document provides a sample letter of medical necessity that can be customized for a patient. The letter is intended to explain the physician's rationale for choosing a specific therapy and help obtain prior authorization or coverage from a health insurance payer. It includes fillable fields for the patient's information, diagnosis, medical history, previous treatments tried, and the physician's recommendation and plan for the requested treatment. The letter aims to document that the therapy is medically necessary for the patient.

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    sample-letter-of-medical-necessity

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    This document provides a sample letter of medical necessity that can be customized for a patient. The letter is intended to explain the physician's rationale for choosing a specific therapy and help obtain prior authorization or coverage from a health insurance payer. It includes fillable fields for the patient's information, diagnosis, medical history, previous treatments tried, and the physician's recommendation and plan for the requested treatment. The letter aims to document that the therapy is medically necessary for the patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    402 views2 pages

    Sample Letter of Medical Necessity

    Uploaded by

    Min Soe
    This document provides a sample letter of medical necessity that can be customized for a patient. The letter is intended to explain the physician's rationale for choosing a specific therapy and help obtain prior authorization or coverage from a health insurance payer. It includes fillable fields for the patient's information, diagnosis, medical history, previous treatments tried, and the physician's recommendation and plan for the requested treatment. The letter aims to document that the therapy is medically necessary for the patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    SAMPLE LETTER OF MEDICAL NECESSITY

    Payers may require prior authorization or supporting documentation in order to process and
    cover a claim for the requested therapy. A prior authorization allows the payer to review the
    reason for the requested therapy and to determine medical appropriateness. A patient-specific
    letter of medical necessity will help to explain the physician’s rationale and clinical decision
    making in choosing a therapy. Please see page 2 for a sample letter of medical necessity with
    fillable fields that can be customized based on your patient’s medical history and demographic
    information and then printed. Please note that some payers may have specific forms that must be
    completed in order to request prior authorization or to document medical necessity.
    [Date]

    [Contact Name of medical director or other payer representative]


    [Contact Title]
    [Name of Health Insurance Company]
    [Address]
    [City, State, Zip]

    Re: Letter of Medical Necessity for [Product] [Strength]

    Patient: [Patient Name]


    Group/policy Number: [Number]
    Date(s) of service: [Dates]
    Diagnosis: [Code & Description]

    Dear [Insert contact name or department] :

    I am writing on behalf of my patient, [PATIENT NAME] , to


    [REQUEST PRIOR AUTHORZATION/DOCUMENT MEDICAL NECESSITY] for treatment with [Product] .
    [Product] is indicated for treatment of [Indication Statement] . This letter serves to document
    that [PATIENT NAME] has a diagnosis of [DIAGNOSIS] and needs treatment with
    [Product] , and that [Product] is medically necessary for [him/her] as prescribed. On behalf
    of the patient, I am requesting approval for use and subsequent payment for the treatment.

    Patient Medical History and Diagnosis


    [PATIENT NAME] is a [AGE]-year-old [MALE/FEMALE] diagnosed with [DIAGNOSIS] .
    [NAME OF PATIENT] has been in my care since [DATE] . As a result of [DIAGNOSIS] , my
    patient [ENTER BRIEF DESCRIPTION OF PATIENT HISTORY] .
    Additionally, [PATIENT] has tried [PREVIOUS THERAPIES] and [OUTCOMES] . The
    attached medical records document [PATIENT NAME] ’s clinical condition and medical necessity for
    treatment with [Product] .

    Based on the above facts, I am confident that you will agree that [Product] is indicated and medically
    necessary for this patient. The plan of treatment is to start the patient on [Product] , monitor platelet
    count and response to therapy and adjust dose accordingly.

    Please consider coverage of [Product] on [PATIENT NAME] ’s behalf, and approve use and
    subsequent payment for [Product] as planned. Please refer to the enclosed Prescribing Information
    for [Product] . If you have any questions regarding this matter, please do not hesitate to call me at
    [PHYSICIAN TELEPHONE NUMBER]. Thank you for your prompt attention.

    Sincerely,
    [PHYSICIAN NAME] , <DEGREE INITIALS>
    [PROVIDER IDENTIFICATION NUMBER]

    Enclosures:
    Prescribing Information (PI)
    [Clinic notes & labs] <If applicable>
    MAT-INC-00488

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