Sample Letter Of Medical Necessity

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SAMPLE LETTER OF MEDICAL NECESSITY 
Payers  may  require  prior  authorization  or  supporting  documentation  in  order  to  process  and  cover  a  claim  for  the  requested  therapy.  A  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.  
 
[Date] 
[Contact Name of medical director or other payer representative] 
[Contact Title] 
[Name of Health Insurance Company] 
[Address] 
[City, State, Zip] 
 
Re: Letter of Medical Necessity for [Product] [strength]  
 
Patient: [Patient Name]  
Group/policy Number: [Number] 
Date(s) of service: [Dates] 
Diagnosis: [Code & Description] 
 
Dear [Insert contact name or department]: 
 
I am writing on behalf of my patient, [PATIENT NAME], to [REQUEST PRIOR AUTHORZATION/DOCUMENT MEDICAL NECESSITY] for 
treatment  with  [Product].  [Product]  is  indicated  for  treatment  of  [Indication  Statement].This  letter  serves  to  document  that 
[PATIENT NAME] has a diagnosis of [DIAGNOSIS] and needs treatment with [Product], and that [Product] is medically necessary for 
[him/her] as prescribed. On behalf of the patient, I am requesting approval for use and subsequent payment for the treatment. 
 
Patient Medical History and Diagnosis 
[PATIENT NAME] is a [AGE]‐year‐old [MALE/FEMALE] diagnosed with [DIAGNOSIS]. [NAME OF PATIENT] has been in my care since 
[DATE]. As a result of [DIAGNOSIS], my patient [ENTER BRIEF DESCRIPTION OF PATIENT HISTORY]. Additionally, [PATIENT] has tried 
[PREVIOUS THERAPIES] and [OUTCOMES]. The attached medical records document [PATIENT NAME]’s clinical condition and medical 
necessity for treatment with [Product]. 
 
Based on the above facts, I am confident that you will agree that [Product] is indicated and medically necessary for this patient. The 
plan of treatment is to start the patient on [Product], monitor platelet count and response to therapy and adjust dose accordingly. 
 
Please  consider  coverage  of  [Product]  on  [PATIENT  NAME]’s  behalf,  and  approve  use  and  subsequent  payment  for  [Product]  as 
planned. Please refer to the enclosed Prescribing Information for [Product]. If you have any further questions regarding this matter, 
please do not hesitate to call me at [PHYSICIAN TELEPHONE NUMBER]. Thank you for your prompt attention to this matter. 
 
Sincerely, 
[PHYSICIAN NAME], <DEGREE INITIALS> 
[PROVIDER IDENTIFICATION NUMBER] 
 
Enclosures: (Attach as appropriate) 
FDA approval letter 
Prescribing Information (PI) 
Clinic notes & labs 
 
CC: [Medical Director, patient, specialty society, Insurance Commissioner] 
 
RUX 1055j 

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