Letter Of Medical Necessity Template printable pdf download

Letter of medical necessity

To be included with claim along with patient records

Place letter on clinician letterhead

Date

Name of insurer

Address

Dear_________:

Patient (Name)_________ has been diagnosed with Diagnosis and ICD10CM______________________

and will start chemotherapy treatment on (Date)____________. I am writing on behalf of the patient to

document medical necessity for Paxman Scalp cooling therapy for the prevention of chemotherapy-

induced hair loss due to Diagnosis and ICD10CM_____________. The Paxman Cooling System, is an FDA

cleared device (DEN150010) and is used to reduce the likelihood of chemotherapy-induced alopecia.

The treatment regimen with the Paxman Cooling system is to use it before (30 minutes prior), during the

IV administration of chemotherapy, and after (90-120) minutes after chemotherapy has been

discontinued). The Paxman Cooling System requires direct supervision and utilizes a patient-specific

cooling cap preloaded with the number of cooling cycles that corresponds to the number of times the

patient will receive chemotherapy. Patient (Name)__________ has been prescribed (Number)____ of

chemotherapy administrations and will require (Number)____ of preloaded cooling cycles.

Systematic reviews and meta-analyses have demonstrated a statistically significant reduction in hair

1,2

loss

. The studies reviewed and reported on in the medical literature have included randomized

controlled trials and; prospective single arm/historical control trials. The vast majority of these peer

reviewed articles have demonstrated a positive effect of scalp hypothermia in reducing hair loss; no

matter the type of scalp hypothermia system used. When combining these studies for meta-analysis

purposes, the effect is statistically significant, favoring scalp hypothermia’s ability to minimize hair loss.

Reducing the incidence of hair loss during chemotherapy for cancer minimizes hair loss’s effect on a

3,4

patient’s anxiety, distress, depression, negative body image, and; lowered self-esteem

. Thus

minimizing hair loss is an important consideration in light of the patient’s condition. Recently there were

4,5

2 US prospective studies that also demonstrated the beneficial effects of scalp cooling

Please contact us with any questions at:______________________

Sincerely,

Name of physician

Shin H et al. Efficacy of interventions for prevention of chemotherapy-induced alopecia: A systematic review and

meta-analysis. International Journal of Cancer 2014;136:E442-E454

Poder TG et al. Effectiveness of scalp cooling in chemotherapy. Bulletin du Cancer 2011;98(9):1119-1129.

Hesketh PJ et al. Chemotherapy-induced alopecia: psychosocial impact and therapeutic approaches. Support Care

Cancer 2004;12:543-549.

Lemieux J et al Chemotherapy-induced alopecia and effects on quality of life among women with breast cancer: a

literature review. Psycho-Oncology 2008;17:317-328.

5. Hope S Rugo MD et al: Association between use of Scalp cooling Device and alopecia after chemotherapy for

breast cancer. JAMA.2017;217(6):606-614.

Letter Of Medical Necessity Template

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