EXAMPLE LETTER #3 OF MEDICAL
NECESSITY
A skillfully
drafted letter of medical necessity is an essential part of a request for
funding for assistive technology. A letter of medical necessity, whether being
submitted to the Department of Human Services, a private insurance company or
other funding source, should contain the information needed to convince the
reader that the requested assistive technology is necessary to meet the medical
needs of the person for whom the assistive technology is being requested. This
fact sheet is intended as a guide to preparing such a letter of medical
necessity.
The letter of medical
necessity should be written by a medical professional familiar with the requesting
party's medical condition. The professional should briefly describe their
credentials and relationship to the requesting party. This professional may
be a physician, a nurse, a physical therapist, an occupational therapist or
other medical professional. However, note that most funding sources require
a physician's prescription as part of the funding request. Therefore, letters
of medical necessity not written by a physician should be endorsed by a physician
or accompanied by a physician's prescription.
ELEMENTS OF A LETTER OF MEDICAL NECESSITY
1. Disability Description - The letter should contain, usually at the beginning, a thorough description of the requesting party's disability. This description should include an explanation of how the disability affects the requesting party's function. For example, the affects of the disability on the use and function of the requesting party's legs. The disabling condition(s) and/or functional limitation(s) which necessitate the request for the assistive technology should be highlighted.
2. Assistive Technology
Description - The assistive technology being requested should be described
in some detail. A more thorough description is required when the requested
technology is new, unique, customized or not frequently requested.
3. Assistive Technology Relationship to Medical Needs - The letter should explain how the requested assistive technology addresses the requesting party's medical needs or functional limitations. Generally in this context, a medical need is not a need to receive medical treatment. Rather, it is a need to compensate for a function which is limited as a result of a disability. For example, a requesting party has a medical need for a wheelchair to compensate for lost function in the lower extremities and to have a functional means of mobility.
4. Inability of Alternatives to Meet Medical Needs - Where there are alternatives, especially less expensive alternatives, available to meet the requesting party's medical needs, the letter should explain why these alternatives are not appropriate for the requesting party. Also, the specific features which make the requested technology the necessary and appropriate alternative should be identified.
5. Ability to Use Technology - The letter should detail the requesting party's ability to use the requested assistive technology. This is especially important when the technology is motorized, electronic or particularly sophisticated. For example, when a power wheelchair is being requested, the requesting party's ability to safely operate a power wheelchair should be noted. If there was a trial with the requested device the results of this trial should be summarized.
6. Requested Assistive
Technology as Community Standard- The letter should justify and explain the
requesting party's need for the assistive technology. This justification should
be in terms of the community standard of practice by the medical professional's
peer group. The medical professional should explain that it is the standard
practice or current practice in their medical profession to provide the requested
assistive technology to persons with the requesting party's disability.
The letter that follows is a sample letter of medical necessity. The numbers contained in the letter correspond to the numbered elements of a letter of medical necessity.
This fact sheet
was produced with funds from the Governor's Advisory Council on Technology for
People with Disabilities/STAR Program funded by the National Institute on
Disability and Rehabilitation Research under the Technology-Related Assistance
for Individuals with Disabilities Act of 1988 as amended, P.L. 103-018. This
fact sheet may be reproduced; if reproduced in its entirety, with credit to the
The Minnesota
Disability Law Center 430 First Avenue N., Suite 300 Minneapolis, MN 55401-1780
Toll Free Number: 1-800-292-4150
December
20, 1994
RE: Ms. Jane Doe
Clinic#:
4-124-109
DOB:
TO WHOM IT MAY CONCERN:
Ms. Jane Doe is a 30-year-old
woman with C5-6 quadriplegia related to a motor vehicle accident in 1985.
Despite her significant disabilities, she had been able to achieve independent
living with the assistance of a personal care attendant. However, she continues
to have difficulties with environmental controls within her home due to her
impaired upper extremity function.
Due to Ms. Doe's high level
of injury, she is unable to use her upper extremities to control her
environment. She is in need of being provided with appropriate technology for
permanent use. I recommend that a voice recognition system from Advanced Speech
Interface Systems, Inc., be purchased and installed in
Ms. Doe's present residence. This company has demonstrated their equipment to
us and will be able to provide ongoing service of their product.
This system is medically
necessary and is accepted among the medical community because it provides
persons with C5-6 quadriplegia (like Ms. Doe) independent living to generate
self-care and self-esteem as mandated under federal law. 6In order to maximize
Ms. Doe's functional independence, an environmental control system is medically
necessary. She would benefit from a voice-controlled system that allows her the
ability to control many functions within her home such as opening doors to exit
her residence in emergency situations such as a fire since she is currently
unable to do this without the assistance of a personal care attendant. This
system will also allow her to change the room temperature to prevent
hypothermia since a person with C5-6 quadriplegia has difficulty maintaining a
normal body temperature. In addition, it will provide her with the means to
dial a phone by using voice commands in the event of an emergency. Because of
her condition, this system will increase her functional capabilities and
decrease her need and use for a personal care attendant.
Ms. Doe needs this system
immediately. She is not going to recover nor regain any of her functional
ability due to her disabling condition which occurred nine years ago. I
recommend that this system be provided by Advanced Speech Interface Systems,
Inc. This company has been in this field of expertise for ten years. They are a
recognized medical assistance provider, and they are supported by the medical
community. The system provided by Advanced Speech Interface Systems, Inc., will
be customized to Ms. Doe's medical needs. Because this system will -be
specifically catered towards her health needs, it represents an effective and
appropriate use of program funds.
If you have any questions, please
contact me.
SIGNED: _____________________
Philip Physician, M.D.
Physical Medicine and Rehabilitation
Specialist