What information should be included in a letter of medical necessity (LMN)?

Essential Components of a Letter of Medical Necessity (LMN)

A letter of medical necessity should be written only after conferring with members of the healthcare team who have evaluated the patient, and should clearly state that the physician has reviewed the evaluation reports, concurs with the recommendations, and confirms that the requested devices or services are medically necessary for treatment of the patient's specific condition. 1

Core Components to Include in an LMN

• Patient Information: Include complete demographic information, name, address, telephone number, and if applicable, the patient's personal care provider or medical home 1

• Diagnosis and Clinical Status:

  • Clearly state the specific diagnosis causing the medical need 1
  • Document the patient's current clinical status related to the diagnosis 1
  • Include relevant medical history that supports the necessity of the requested service or device 1

• Recommended Treatment/Device:

  • Specify exactly what is being requested (device, service, medication) 1
  • Include details about why this specific intervention is required 1
  • For devices, include specifications and features necessary for the patient 1

• Medical Justification:

  • Explain why the requested item/service is medically necessary 1
  • Describe how the patient's condition specifically necessitates this intervention 1
  • Detail how the requested item/service will treat the impairment caused by the specific diagnosis 1

• Expected Outcomes:

  • Document the anticipated benefits and functional improvements 1
  • Describe how the intervention will improve morbidity, mortality, or quality of life 1
  • Include information about the expected outcome after using the device/service 1

• Alternative Treatments:

  • Describe previous treatments attempted and why they were inadequate 1
  • Explain why alternative options are not appropriate or have failed 1

• Supporting Evidence:

  • Reference relevant clinical guidelines or research supporting the request 1
  • Include copies of evaluation reports from specialists (e.g., speech-language pathologists for communication devices) 1

• Physician Statement:

  • Include a clear statement that the physician has reviewed all relevant reports 1
  • Explicitly state that the requested item/service is "medically necessary" 1
  • Include your signature, credentials, and contact information 2

Best Practices for Effective LMNs

• Be Specific and Detailed: Funding agencies need more than just diagnoses or physical examination reports; provide complete and clear information 1

• Use Clear Medical Language: Avoid ambiguity while ensuring the letter remains comprehensible to non-medical reviewers 2

• Focus on Function: Emphasize functional limitations and how the requested item addresses these limitations 1

• Anticipate Objections: Address potential concerns from insurers proactively 1

• Cite Relevant Guidelines: Reference peer-reviewed literature on clinical validity and utility when appropriate 1

• Avoid Experimental Terminology: Frame the request as established treatment rather than experimental 1

Common Pitfalls to Avoid

• Insufficient Detail: Vague descriptions of medical necessity are frequently grounds for denial 1

• Missing Documentation: Failure to include supporting specialist evaluations can lead to rejection 1

• Focusing Only on Diagnosis: Emphasize functional limitations, not just the diagnostic code 1

• Overlooking Insurance Requirements: Different payers have specific requirements; tailor the letter accordingly 1

• Using Template Language: While templates can help, customize each letter to the specific patient's needs 2

• Neglecting to Address Permanence: For certain conditions, address whether the condition is permanent if required by the insurer 1

For particularly challenging cases, consider consulting with funding specialists who may be available through device manufacturers or healthcare systems to navigate specific payer requirements 1.