EXAMPLE LETTER #1 OF MEDICAL NECESSITY
The following example letter of medical necessity and advice
are only intended to assist you in
writing your own letter to aid in securing funding for medical equipment. It is in no way implied that if you use this example
you will be granted funding for medical equipment. Our only intention is to share information
that we have gathered in the past and used by other clients.
The funding agencies that would be in
charge of compensation for such medical items, such as your insurance company
or a private philanthropic organization, almost always demand a letter of
medical necessity from a therapist (physical, occupational, or otherwise) or
from a physician to prove your claim that your child’s medical equipment was necessary
to his successful treatment. The claim or appeal will be likely be refused if
you do not include a letter of medical necessity which includes a detailed
explanation of the condition or disability that makes the equipment a necessity
for your loved one.
It
is possible that your particular physician may not fully be acquainted with the
rules of your insurance company which will affect whether or not you are
reimbursed for your child’s medical equipment. (Each insurance company or state
may have slightly different rules.) To be on the safe side, educate yourself on
the rules so that you can be a better advocate for your family. You should
become familiar with the bare minimum of information that needs to be included
in a letter of medical necessity. Otherwise, the letter may contain
insufficient information, which may lead to the funding agency denying your
claim.
The
following is an example of a thorough and professional letter of medical necessity
taken from Dr. Freeman Miller’s Cerebral Palsy: A Complete Guide for Care
giving. If you prefer, you can take a copy of this letter to the physician
who is writing your child’s letter of medical necessity, and ask that he or
she adhere to the example letter below.
“To Whom It May Concern (or, better, to a specific employee of the funding agency):
John Smith is a 5-year-old male with a primary diagnosis of cerebral palsy.
He was seen at the Seating Clinic at the John Doe Institute in Anywhere,
John presents with the following: generally decreased tone in upper and lower
extremities, and fair head and trunk control. He is dependent in transfers
and mobility. He is cognitively severely delayed. He is incontinent in bowel/bladder.
He has frequent respiratory complications and is subject to bronchitis and
pneumonia, and he receives chest therapy. He occasionally aspirates, he has
increased skin sensitivity, and he has seizures, but they’re generally under
control with his medication. He must have safe sleeping environment to eliminate
the danger of falls and entrapment with appropriate positioning to provide
safety and support, and to facilitate safe sleeping, breathing and feeding.
His current bed is
a ___________ that is three years old. It no longer meets his bedding needs
because he has outgrown it, and it poses safety concerns because_____________________.
The goals for John’s sleeping and resting is to provide a safe sleeping
environment where falls and entrapment no longer pose a threat for harm and to
foster a comfortable rest, maintain posture, provide comfort, and enhance
function. Upon evaluation, _____________________ has recommended that the
following equipment be prescribed for John:
(Be very specific in the bed model, size, and specific safety features)
the following example is for a wheel chair…rewrite this section
to detail all of the specific features of the recommended bed system….for
example…the Sleep Safe 2 Plus model is prescribed because it offers 22 inches
of safety rail height protection above the mattress, eliminating the risk
of a fall when he is in a sitting position. The “plus” model frame is prescribed because
he is dependant on tube feedings and his head must be elevated during this
time….etc)
The ____________________(is
prescribed because it is a manual wheelchair for total positioning, and because
he is dependent in mobility. The tilt is needed because he is hypotonic in head
and trunk. He also has difficulty breathing, and it will help aid in feeding.
It will help with low endurance and pressure relief, and it will control
seizure reaction. The adjustable height arms are needed to support tray at
right height, for upper body support and balance, and for ease of transfers. The I-back will bring side supports close to trunk, but
insert will fit the full width of the wheelchair. The laterals will encourage
midline trunk position, compensate for lack of trunk control, provide safety,
and contour around trunk for better control. The chest harness is needed for
safety in transport by providing anterior support, preventing forward flexion,
and retracting shoulders. The headrest is needed for poor head control due to
low tone, active flexion of head, posterior lateral support, safety in transfers,
and to facilitate breathing. The clear tray is needed for functional surface
for schoolwork, stimulation, upper arm and trunk support, inability to access
tables, computer, and a base for augmentative communication devices. The shoe
holders are needed to control increased extension or spasms in lower
extremities, excessive internal rotation, and to prevent aggressive behavior
for safety. The anti-tippers are needed for safety.
Should you have any questions regarding these recommendations, please do not hesitate to call me at (555) 555-5555. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistance in this manner.
Sincerely,
John Doe,
M.D.
Pediatric Orthopedic Surgeon”
Be
sure to take note of when your child’s letter was sent to the funding agency,
and if three or four weeks pass without word from them, you might want to call
the agency to inquire about the status of your claim. Always keep a record of
when you call and with whom you speak to, and always try to remain calm and
collected when dealing with the insurance company. If, however, you are unable
to obtain a straightforward response as to when your claim will be processed,
do not hesitate to enlist the help of your physician.