Letter of medical necessity
A letter from your doctor saying why you need the care. Draft it here; your doctor signs it.
Already denied? Build an appeal and send this letter with it.
How to use it
- 01The letter must come from your clinician, on their letterhead, with their signature. Send them this draft through your patient portal.
- 02The doctor’s office usually submits it with the prior authorization request. Ask when they sent it and the request number.
- 03Ask for the plan’s medical policy or coverage criteria for this service, and make sure the letter addresses each criterion.
- 04If the plan still says no, the doctor can ask for a peer-to-peer review: a call with the plan’s reviewing doctor.
Message to your doctor’s office
Hi, I’m a patient of Dr. [name]. My insurance needs approval for [test, drug, equipment, or procedure]. Could the doctor send a letter of medical necessity with the request? I drafted one to save time; the doctor can edit it however they like. Thank you.
Draft letter for your doctor
Still yours to fill: Your name; Date of birth; Member ID; Request number, if any; Plan name. The doctor’s office fills the 13 other blanks.
The office fills in the rest of the [bracketed] parts, edits anything, and signs it. Only your doctor can say a treatment is medically necessary: the letter has to match their judgment and your records.
[Clinic letterhead] [Date] [Plan name] [Utilization Management / Prior Authorization Department, address or fax] Re: Letter of medical necessity for [test, drug, equipment, or procedure] Patient: [Patient name] Date of birth: [DOB] Member ID: [Member ID] Request number, if any: [Number] Diagnosis: [Diagnosis] [ICD-10 code] Requested: [test, drug, equipment, or procedure] [CPT, HCPCS, or NDC code; quantity or number of visits] To whom it may concern: I am writing to request prior authorization for [test, drug, equipment, or procedure] for my patient, whom I am treating for [diagnosis]. The results will directly change my management of this patient’s care. A physical exam and less advanced testing have not been sufficient to establish the diagnosis or guide treatment. [List treatments already tried, with dates and why each was stopped: not effective, side effects, or not tolerated.] [Describe the expected harm if it is not provided: worsening symptoms, loss of function, hospitalization, or other risks.] This request is consistent with [clinical guideline, FDA labeling, or the plan’s own medical policy number]. Please contact my office at [phone] if you need more information, or to schedule a peer-to-peer review. Sincerely, [Clinician name, credentials] [NPI] [Practice name, phone, fax] Enclosures: Recent office notes with exam findings and symptoms; Results of earlier tests or imaging; The CPT code for the test and the ICD-10 diagnosis codes
Records to send with it
- Recent office notes with exam findings and symptoms
- Results of earlier tests or imaging
- The CPT code for the test and the ICD-10 diagnosis codes
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