"Letter of Medical Necessity Template"

What Is a Letter of Medical Necessity?

A Letter of Medical Necessity is a written statement prepared by the physician to describe the current diagnosis of the patient and recommend treatment and medication. This document may be required for reimbursement if the treatment entails expenses that must be covered by the insurance provider or for the medical facility that needs a professional opinion of the doctor that knows the patient well and can provide them with basic details about the patient's medical history and prognosis. You can download a Letter of Medical Necessity sample below.

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How to Write a Letter of Medical Necessity?

You may customize a Letter of Medical Necessity template the way you deem correct - there is no uniform format, and as long as this document contains all important details about the patient's health condition and you offer the recipient a chance to contact you and know more, this statement will be accepted and reviewed.

Follow these steps to compose a Medical Necessity Letter:

  1. Greet the recipient - if you know the individual who will review your documentation, you should address them by their name; otherwise, it would fine to simply write "To whom it may concern".
  2. Introduce yourself and state your name and position. Indicate the purpose for writing the letter - you are preparing this statement on behalf of your patient.
  3. Record the date you last assessed the individual in question. Add the name of the patient and specify the treatment they require, the medication they must be prescribed, or the equipment they must be provided with. Explain your diagnosis and shortly summarize your professional opinion about the possibility of recovery. If you need to attach documentation that outlines the patient's medical history and diagnosis more extensively, you may refer to the enclosed files, but keep the references comprehensible to make it all clear to the letter reader. Make sure you describe why the treatment and/or medication are medically necessary in accordance with the requirements and rules established by the party that requested the letter - for instance, the insurance company may ask you to calculate the cost of treatment and explain the patient' life is in danger or they may develop a handicap.
  4. State the duration of the required treatment, medication timing and dosage, and other necessary details you recommend adhering to. Note that the period you indicate should not exceed one year - after that time, it is a good idea to prepare another Medical Letter of Necessity to update information.
  5. Add your contact information and offer the recipient of the letter to call or write to you if they have any questions or concerns.
  6. Sign and date the letter and give it to the patient or send it directly to the medical provider or insurance company that requested it. Make another copy of the letter and keep it in the patient's records - you may need to expand on it in the future or present it as evidence if the recipient refuses to provide the patient with treatment or equipment.

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Letter of Medical Necessity
Payers may require prior authorization or supporting documentation in order to process and cover a claim
for the requested therapy. 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. The following is a sample letter of medical necessity that can be
customized based on your patient’s medical history and demographic information. Please note that some
payers may have specific forms that must be completed in order to request prior authorization or to
document medical necessity.
From: _​ _ _________________________
To:​ _ _____________________________
Sender’s (Physician’s) Name
Contact Name of Medical Director or Other
_________________________________
Payer Representative
_________________________________
Provider Identification Number (PIN)
Contact Title
_________________________________
_________________________________
_________________________________
Contact Address
Sender’s Address
_________________________________
_________________________________
City, State, ZIP Code
City, State, ZIP Code
_________________________________
D ate
Re: ​ L etter of Medical Necessity for [​
P roduct​
] [​
S trength​
]
Dear ____________________________,
Insert Contact Name or Department
I am writing on behalf of my patient, [​
P atient Name​
] , group/policy number [​
N umber​
] ,
date(s) of service - [​
D ates​
] . I would like to [​
r equest prior authorization/document medical
necessity​
] for treatment with [​
P roduct​
] . [​
P roduct​
] is indicated for the treatment of
[​
I ndication Statement​
] .
This letter serves to document that [​
P atient Name​
] has a diagnosis of [​
D iagnosis​
] and
needs treatment with [​
P roduct​
] and that [​
P roduct​
] is medically necessary for them as
© ​
T EMPLATEROLLER.COM
Letter of Medical Necessity
Payers may require prior authorization or supporting documentation in order to process and cover a claim
for the requested therapy. 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. The following is a sample letter of medical necessity that can be
customized based on your patient’s medical history and demographic information. Please note that some
payers may have specific forms that must be completed in order to request prior authorization or to
document medical necessity.
From: _​ _ _________________________
To:​ _ _____________________________
Sender’s (Physician’s) Name
Contact Name of Medical Director or Other
_________________________________
Payer Representative
_________________________________
Provider Identification Number (PIN)
Contact Title
_________________________________
_________________________________
_________________________________
Contact Address
Sender’s Address
_________________________________
_________________________________
City, State, ZIP Code
City, State, ZIP Code
_________________________________
D ate
Re: ​ L etter of Medical Necessity for [​
P roduct​
] [​
S trength​
]
Dear ____________________________,
Insert Contact Name or Department
I am writing on behalf of my patient, [​
P atient Name​
] , group/policy number [​
N umber​
] ,
date(s) of service - [​
D ates​
] . I would like to [​
r equest prior authorization/document medical
necessity​
] for treatment with [​
P roduct​
] . [​
P roduct​
] is indicated for the treatment of
[​
I ndication Statement​
] .
This letter serves to document that [​
P atient Name​
] has a diagnosis of [​
D iagnosis​
] and
needs treatment with [​
P roduct​
] and that [​
P roduct​
] is medically necessary for them as
© ​
T EMPLATEROLLER.COM
prescribed. On behalf of the patient, I am requesting approval for use and subsequent
payment for the treatment.
Patient Medical History and Diagnosis
[​
P atient Name​
] is a [​
A ge​
] -year-old [​
M ale/Female​
] diagnosed with [​
D iagnosis​
] . [​
P atient
Name​
] has been in my care since [​
D ate​
] . As a result of [​
D iagnosis​
] , my patient [​
a brief
description of patient history​
] . Additionally, [​
P atient Name​
] has tried [​
P revious
Therapies​
] and [​
O utcomes​
] . The attached medical records document [​
P atient Name​
] ’s
clinical condition and medical necessity for treatment with [​
P roduct​
] .
Based on the above facts, I am confident that you will agree that [​
P roduct​
] is indicated
and medically necessary for this patient. The plan of treatment is to start the patient on
[​
P roduct​
] and monitor and follow up as appropriate.
Please consider coverage of [​
P roduct​
] on [​
P atient Name​
] ’s behalf, and approve use and
subsequent payment for [​
P roduct​
] as planned. Please refer to the enclosed Prescribing
Information for [​
P roduct​
] . If you have any further questions regarding this matter, please
do not hesitate to call me at [​
S ender’s (Physician’s) Telephone Number​
] . Thank you for
your prompt attention to this matter.
Sincerely,
[​
S ender’s (Physician’s) Name​
] , [​
D egree Initials​
]
[​
P rovider Identification Number (PIN)​
]
Enclosures: (Attach as appropriate)
● FDA Approval Letter;
● Prescribing Information (PI);
● Clinic Notes & Labs.
CC: Medical Director, Patient, Specialty Society, Insurance Commissioner
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T EMPLATEROLLER.COM
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