Letter Of Medical Necessity Template

Download a blank fillable Letter Of Medical Necessity Template in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Letter Of Medical Necessity Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


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
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)


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Page of 2