Fillable Letter Of Medical Necessity Template printable pdf download

The Federal FSA Program

Letter of Medical Necessity (LMN)

Under Internal Revenue Service (IRS) rules, some health care services and products are only eligible for

reimbursement from your Health Care Flexible Spending Account (HCFSA) or Limited Expense Health

Care Flexible Spending Account (LEX HCFSA) when your doctor or other licensed health care provider

certifies that they are medically necessary.

Your provider must indicate your (or your spouse’s or dependent’s) specific diagnosis, the specific

treatment needed, the length of treatment, and how this treatment will alleviate your medical

condition.

You may either submit the LMN with your medical claim, or you may submit the LMN prior to

submitting a medical claim in order to determine if the expense will be eligible for reimbursement.

Please use the following guidelines when submitting an LMN:



The diagnosis must be specific. For example, a diagnosis of “elevated levels of triglycerides or

cholesterol” is not specific – a diagnosis of “hypercholesterolemia” is specific.



The recommended treatment must be named and described in detail by your licensed health

care provider. A recommended treatment described as “regular or daily exercise recommended

for weight loss” is not enough information. Your provider must specifically name and describe

the recommended treatment. An acceptable description of treatment would be “I recommend

an exercise program through a gym membership for the next 6 months to alleviate the patient’s

hypertension.” If you are claiming membership to a health club, you must certify that you were

not already a member of a health club.



Your provider must state a specific length of treatment (not to exceed 12 months). Lifetime or

indefinite lengths of treatment will not be approved. If the treatment is for a chronic condition,

you only need to submit one LMN for the Benefit Period.



Your licensed provider must complete, sign and date the form.

FSAFEDS has developed the form on the following page to assist you and your health care provider in

providing the information we need in order to process your claim. Your provider can also submit a

statement on his or her letterhead, as long as the letter includes all of the information on this form.

If you have questions you may visit the FSAFEDS web site at

or contact an FSAFEDS

Benefits Counselor, toll‐free, at 1‐877‐FSAFEDS (372‐3337), TTY: 1‐800‐952‐0450, Monday through

Friday, 9:00

. until 9:00

., Eastern Time.

The Federal FSA Program

FSAFEDS Program  PO Box 36880  Louisville, KY 40233 

 1‐877‐FSAFEDS (372‐3337)

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Letter Of Medical Necessity Template