Sample Letter Of Medical Necessity Template

Download a blank fillable Sample 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 Sample 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.

ADVERTISEMENT

Sample Letter of Medical Necessity
DATE
:
________________
To Whom it May Concern,
has been under my care since
[PATIENT NAME]________________________
[DATE TREATMENT BEGAN]
_______________________
and suffers from generalized, severe plaque psoriasis on over 10% of his/her body surface area. The
patient also has a long history of frequent and debilitating flare-ups necessitating immediate treatment
to control the disease and return their quality-of-life to an acceptable state.
has tried numerous topical and oral medications, which have produced
_______________________________________________
less-than-satisfactory results.
has received treatment with nb-UVB therapy in a clinical setting,
___________________________________________________
which has proven extremely effective in reducing or completely eliminating their disease. It is my
conclusion as a medical expert that nb-UVB therapy is by far the best modality for
.
_______________________________________________
Because Psoriasis is an incurable, life-long condition that requires continual treatment,
_________________________
will have the greatest quality of life receiving indefinite UV treatment at
least 3 times a week, adjusting for periods of more or less sun exposure.
Given that a regimen of 3 clinic visits per week for the indefinite length of
_______________________
is
impractical and extremely inconvenient for any individual, I am strongly recommending a home
phototherapy unit for
______________________
as the best way to dramatically improve their quality
of life.
In addition to the superior effectiveness of UV treatments to biologics such as Enbrel and Humira, a
home phototherapy system is more cost-effective than either clinic-based phototherapy or a biologic
regimen. Given standard co-pays,
_________________________
will pay approximately $3,000- $5,000
per year for clinic visits, and approximately $5,000 - $10,000 annually for treatment with leading
biologics and biosimilars.
In contrast, a home phototherapy unit will be a one time purchase of approximately $3,000 - $5,000,
depending on condition.
I am strongly recommending that
_______________________
receive a UVBioTek home phototherapy
unit for home-centered narrow-band ultraviolet light treatment. UVBioTek offers the highest quality,
safest and most spatially-economic home phototherapy units.
I have full confidence that ____________________________is competent and able to operate a home
phototherapy unit within the treatment parameters I have determined.
Sincerely,
DOCTOR NAME:
DOCTOR SIGNATURE:
Form 7.2.2-76F Rev B

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Letters
Go