Sample Letter Of Medical Necessity Template
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1
2February 10, 2013
Blue Cross Blue Shield
45 North Olson Avenue
Anytown, Illinois 65432
RE:
Letter of Medical Necessity
Your Beneficiary:
xxxxx xxxxx
Group ID #:
xxxxxxx
Personal ID #:
xxxxxxx
Dear Blue Cross Blue Shield:
This is a letter of medical necessity (LMN) for your beneficiary XXXXXX. He/she was
initially examined at our office on November 13, 2012 with follow-up visits on
November 23 and December 28, 2012. His/her diagnosis is:
Keratoconus, ICD: 371.60.
Best corrected vision with spectacles was measured as:
OD / right eye:
20 / 50
OS / left eye:
20 / 40
A refraction revealed the following prescription:
OD / right eye:
- 9.00 – 1.25 x 55 = 20 / 25
OS / left eye:
- 9.75 – 1.00 x 135 = 20 / 25
However, after ZZZZZ received his fitting for mini scleral gas permeable contact
lenses, his best corrected distance vision was measured as:
OD / right eye:
20 / 25
OS / left eye:
20 / 25
Keratoconus is a progressive eye disease which causes a bulging and thinning of the
cornea, leading to image distortion and a loss of best corrected vision. If the disease
progresses, it will lead to severe surface distortion and thinning of the cornea, and
subsequently require a costly corneal transplant for one or both eyes. The blurred
and distorted vision also prevents the patient from wearing any spectacles. Thus,
contact lenses become the only way to see and function.
The medical necessity for contact lenses is due to the need to:
Prevent further progression of the disease,
Difficulty wearing spectacles, a frequent side effect among keratoconus
patients
Restore vision to a level permitting successful passage of a driver’s license
exam.
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