How to Draft a Letter of Medical Necessity for a Patient
A letter of medical necessity should be written only after conferring with members of the healthcare team who have evaluated the patient, clearly stating that you have reviewed their recommendations and concur that the requested device or service is medically necessary for treatment of the patient's specific condition. 1
Essential Components of a Medical Necessity Letter
1. Patient Information
- Full name, date of birth, and insurance ID number
- Diagnosis with ICD-10 code
- Duration of the condition
2. Physician Information
- Your name, credentials, and contact information
- Your relationship to the patient (treating physician)
- Statement of your qualifications relevant to the request
3. Detailed Clinical Justification
- Clearly state that you have reviewed evaluation reports and recommendations from relevant specialists 1
- Explicitly state that you concur the requested item/service is "medically necessary" for treatment of the patient's specific condition 1
- Include the patient's current functional status and limitations
- Document previous treatments attempted and their outcomes
- Explain why the requested item/service is necessary (not just convenient)
- Describe expected outcomes and how they will improve morbidity, mortality, or quality of life
4. Specific Request Details
- Precise description of what is being requested (equipment, service, medication)
- Duration needed (one-time, time-limited, or ongoing)
- Frequency of use or treatment
- Relevant specifications or parameters
5. Supporting Evidence
- Reference relevant clinical guidelines or research supporting your request
- Include copies of pertinent medical records, test results, or specialist evaluations
Best Practices for Effectiveness
Use clear, direct language: Avoid medical jargon when possible; when necessary, explain technical terms.
Be specific and detailed: Funding agencies need more than just diagnoses or physical examination findings 1. Requests with complete and clear information are most likely to be funded.
Focus on medical necessity: Emphasize how the requested item/service is essential for treating the patient's condition, not merely helpful or convenient.
Address potential denials proactively: Anticipate and counter possible reasons for denial in your letter.
Take the appeal process seriously: If denied, carefully review the denial letter for specific policy statements that can be addressed in an appeal 1. A successful appeal can serve as an important precedent for future requests.
Common Pitfalls to Avoid
- Insufficient clinical detail: Vague descriptions of medical need are frequently grounds for denial.
- Focusing on convenience rather than necessity: The letter must establish medical necessity, not just preference or convenience.
- Failing to document failed alternatives: Not showing that less expensive options have been tried or considered.
- Inconsistent documentation: Ensure all supporting documents align with your request.
Sample Structure
[Date]
[Insurance Company/Funding Agency]
[Address]
RE: Letter of Medical Necessity for [Patient Name], [ID Number]
To Whom It May Concern:
I am writing this letter of medical necessity on behalf of my patient, [Patient Name], to request coverage for [specific item/service]. I have reviewed the evaluation reports and recommendations from [relevant specialists] and concur that this is medically necessary for treatment of [patient]'s [specific diagnosis].
[Patient] is a [age]-year-old [gender] who has been diagnosed with [diagnosis] on [date]. The condition has resulted in [specific functional limitations].
Previous treatments have included [list treatments], which have been unsuccessful because [reasons]. Without the requested [item/service], [patient] will continue to experience [negative outcomes affecting morbidity/mortality/quality of life].
The requested [item/service] is medically necessary because [specific reasons tied to patient's condition]. With this [item/service], we expect [specific improvements in function/health outcomes].
Please contact me at [phone number] if you require any additional information to approve this medically necessary [item/service].
Sincerely,
[Your Name, Credentials]
[Your Title]
[Contact Information]Remember that perseverance is often required when seeking funding approval 1. If your request is denied, carefully review the denial letter and prepare a thorough appeal with additional supporting documentation as needed.