A letter of medical necessity (LMN) is a crucial document often required by insurance companies to authorize treatment, medication, or equipment. It explains why a particular service is medically necessary for a patient’s health and well-being. A well-crafted LMN can significantly increase the chances of approval. This article provides an overview of what to include in your letter, along with 21 samples to guide you. Remember to always tailor the letter to the specific patient and their individual needs.
When writing an LMN, clarity and conciseness are key. The letter should clearly state the patient’s diagnosis, the proposed treatment, and the rationale behind why that treatment is essential. It should also include relevant medical history, diagnostic test results, and any other supporting documentation. Using precise medical terminology and citing relevant medical literature can further strengthen your case. Finally, remember to maintain a professional and objective tone throughout the letter.
21 Sample Letters of Medical Necessity
Below are sample letters for various situations. Remember to adapt these to your specific circumstances.
- Sample 1: General Medical Necessity
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request pre-authorization for [Treatment/Medication] for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and requires [Treatment/Medication] to [Explain the benefit and impact on quality of life]. Without this treatment, [Explain the consequences of not receiving treatment]. Thank you for your consideration.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 2: Physical Therapy
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
[Patient Name] requires physical therapy three times per week for the next six weeks. [He/She] has been diagnosed with [Diagnosis] and is experiencing significant limitations in [Activities of daily living]. Physical therapy will help to improve [Specific goals and benefits of therapy].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 3: Mental Health Services
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting authorization for ongoing psychotherapy sessions for [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and is experiencing [Symptoms and their impact]. Psychotherapy is crucial for managing [His/Her] symptoms and improving [His/Her] overall mental well-being.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 4: Durable Medical Equipment (DME)
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request pre-authorization for a [Type of DME] for my patient, [Patient Name]. [He/She] has [Diagnosis] and requires this equipment to [Explain the need for the DME and its benefits]. Without this equipment, [Patient Name] will experience [Consequences of not having the DME].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 5: Specialist Consultation
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting a consultation with a [Specialist Name/Type] for my patient, [Patient Name]. [He/She] presents with [Symptoms and clinical findings] and requires specialized evaluation and treatment for [Suspected condition]. This consultation is necessary to determine the most appropriate course of action.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 6: Outpatient Surgery
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request pre-authorization for an outpatient [Surgery Name] for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and the surgery is medically necessary to [Explain the reason for the surgery]. The alternative to surgery would be [Consequences of not having surgery].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 7: Prescription Medication
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request prior authorization for [Medication Name] for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and this medication is essential to [Explain how the medication will help and what the alternatives are]. Previous treatments have been [Describe failed treatments and why this medication is needed].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 8: Home Healthcare
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting approval for home healthcare services for [Patient Name]. [He/She] suffers from [Diagnosis] and requires assistance with [Activities of daily living]. Without home healthcare, [Patient Name] is at risk of [Potential complications and risks]. Services should include [Specific services needed, e.g., skilled nursing, physical therapy].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 9: Speech Therapy
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
[Patient Name] requires speech therapy two times per week for the next eight weeks. [He/She] has been diagnosed with [Diagnosis] and is experiencing significant limitations in [Communication skills]. Speech therapy will help to improve [Specific goals and benefits of therapy] and prevent further decline in communication abilities.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 10: Occupational Therapy
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
[Patient Name] requires occupational therapy sessions. [He/She] has been diagnosed with [Diagnosis] and is experiencing significant limitations in [Daily living activities]. Occupational therapy will help to improve [Patient]’s ability to function independently and safely at home by addressing [Specific skills to be improved].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 11: Hospice Care
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
[Patient Name] is terminally ill with a prognosis of six months or less and therefore meets the requirements for hospice care. [He/She] has been diagnosed with [Diagnosis] and is experiencing [List of symptoms and functional decline]. Hospice care will provide comfort, pain management, and emotional support to [Patient] and their family during this difficult time.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 12: Respite Care
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting authorization for respite care services for [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and requires constant care. The primary caregiver(s) are experiencing [Stress and exhaustion] and require temporary relief to prevent caregiver burnout. Respite care will allow the caregiver(s) to rest and recharge, ensuring they can continue providing quality care to [Patient] in the long term.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 13: Psychiatric Medication
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request prior authorization for [Medication Name], a psychiatric medication, for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and has experienced [List of symptoms] significantly impacting their daily functioning. [Medication Name] is necessary to stabilize [Patient]’s mood, reduce symptoms, and improve their ability to engage in therapy and daily activities. Alternatives have been considered, but [Explain why this medication is the best option].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 14: Bariatric Surgery
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting pre-authorization for bariatric surgery (specifically, [Type of Surgery]) for my patient, [Patient Name]. [He/She] has a BMI of [BMI] and has been diagnosed with [List of co-morbidities such as diabetes, hypertension, sleep apnea]. [Patient Name] has attempted medical weight loss management without success. Bariatric surgery is medically necessary to address these health concerns and improve [Patient]’s overall health and quality of life.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 15: Fertility Treatments
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request pre-authorization for [Specific Fertility Treatment, e.g., IVF] for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis leading to infertility] and has been trying to conceive for [Duration]. [Explain the medical necessity of the treatment given the diagnosis and previous unsuccessful attempts at conception]. [Include test results and relevant medical history].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 16: Chiropractic Care
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
[Patient Name] requires chiropractic care to manage [Diagnosis] and related symptoms. [He/She] is experiencing [Describe pain, limited mobility, etc.]. Chiropractic adjustments will help to reduce pain, improve spinal alignment, and restore normal function. Previous treatments have included [List other treatments tried and their outcomes].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 17: Orthotics
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request pre-authorization for custom orthotics for my patient, [Patient Name]. [He/She] has [Diagnosis] and is experiencing [Symptoms related to the condition]. Custom orthotics are medically necessary to provide support, correct biomechanical imbalances, and reduce pain. Standard over-the-counter orthotics are not sufficient due to [Explain why custom orthotics are needed over OTC options].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 18: Hyperbaric Oxygen Therapy (HBOT)
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting pre-authorization for Hyperbaric Oxygen Therapy (HBOT) for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis, e.g., non-healing wound, radiation injury] and HBOT is indicated to [Explain how HBOT will help, e.g., promote healing, reduce inflammation]. [Provide details of the patient’s condition, failed previous treatments, and supporting medical literature].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 19: Genetic Testing
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request pre-authorization for genetic testing for my patient, [Patient Name]. [He/She] has a family history of [Genetic disease] and is exhibiting symptoms suggestive of [Suspected condition]. Genetic testing is medically necessary to confirm the diagnosis, determine the risk of disease transmission to future generations, and guide appropriate treatment and management decisions. [Explain how the results will impact medical decisions].
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 20: Breast Reconstruction Surgery
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am requesting pre-authorization for breast reconstruction surgery for my patient, [Patient Name]. [He/She] underwent a mastectomy as treatment for breast cancer. Breast reconstruction is medically necessary to restore body image, improve psychological well-being, and alleviate physical discomfort. This procedure is an integral part of [Patient]’s cancer treatment plan.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information] - Sample 21: Nutritional Supplements
[Date]
[Insurance Company Name]
[Insurance Company Address]Re: Patient Name: [Patient Name], Date of Birth: [Date of Birth], Policy Number: [Policy Number]
Dear [Insurance Company Representative],
I am writing to request prior authorization for [Nutritional Supplement] for my patient, [Patient Name]. [He/She] has been diagnosed with [Diagnosis] and this supplement is essential to [Explain how the supplement will help and what the alternatives are]. [Patient Name]’s condition creates [specific nutritional deficiencies] and the supplement addresses these needs to promote healing and prevent further complications.
Sincerely,
[Physician Name]
[Physician Credentials]
[Physician Contact Information]
Writing a compelling letter of medical necessity requires careful attention to detail and a clear understanding of the patient’s condition and treatment plan. By using the samples provided as a guide and tailoring them to the specific situation, you can significantly increase the likelihood of obtaining the necessary approvals for your patients. Remember to always include supporting documentation and maintain a professional tone.
