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Writing letters of medical necessity.

With insurance claims, denials and appeals abundant in medical care, there are many variables that can make a difference in the care a patient receives. As most people are dependent on their insurance company to pay for expensive treatments and adaptive devices, everyone involved in the care of a person with a disability should be familiar with how to write a successful Letter of Medical Necessity.

While it is typically the duty of a medical professional to write a Letter of Medical Necessity, there are other people whose opinions can help sway those reviewing the claim. Teachers, case managers, counselors and parents all provide different points of view that are valid to establishing medical necessity. Their description of how the patient functions in various settings and how that can be improved with the desired intervention can not always be provided by a medical professional. While their views should not be submitted alone, they are an excellent complement to a medical opinion.

One of the points that should be addressed in the letter is the definition of "medical necessity." This may vary among different insurance companies and may even change from policy to policy. The best way to find this information is by reading the insurance benefits booklet and taking a close look at the definition provided, as the definition should form the basis and direction of the letter.

The opening paragraph of the letter should introduce both the patient and the evaluator (primary care physician, OT, PT, speech language pathologist, parent or teacher) as well as describe the diagnosis, the patient's current level of functioning and the prognosis.

The body of the letter should further express how the suggested treatment will increase function and why other alternatives are not optimal for progress with the patient's condition. Emphasis should be placed on improving independent control for the patient and his/her safety.

Other points of information, such as how the new treatment may cut costs that will need to be covered in the future or other costs currently being covered should be included in the letter. Explanations of further medical complications that may arise, incurring financial responsibility on the part of the insurance company if the intervention is denied should also be discussed.

If the insurance company decides to reject a claim, there is still an appeal process that can be followed. However, the primary goal of the Letter of Medical Necessity should be to gain approval in the first round, as only a small number of denials are overturned. Remember that during an appeal process, the patient has a right to:

* An explanation of why the claim was denied;

* Clarification of the policy provisions that explain why the claim was denied;

* A report of any additional information that may be needed to perfect the claim for future approval;

* Proper procedures for submitting an appeal.

If, during the appeal process, you feel you may have to file a lawsuit to secure benefits, it is important that you present all the information you would present in the suit, as anything not mentioned in an appeal will not be looked at by a court. For example, without including the opinion of a medical professional in the appeal, you may not be allowed to have an expert witness testify on the patient's behalf.

There are other things to remember when filing a claim. Will there be training involved with the new intervention? Who will need to be trained? The patient? The caregiver? Will regular maintenance be required? Will other forms of intervention require maintenance that is more costly than that of the prescribed treatment? All aspects must be considered carefully.

If the idea of writing a Letter of Medical Necessity produces a stumbling block, it might also help to contact the manufacturers of the intervention in question. While it is unlawful for manufacturers to write and send Letters of Medical Necessity about their products to the insurance companies for the families, many have sample letters that may help point you in the right direction. There are several companies in the special needs arena that provide this service. English Ave Industries, designers of SleepSafe[TM] adaptive beds, CamBrooke Foods, producers of low protein food for special diets, Columbia Medical, who provide unique products for people with physical disabilities and Hard Manufacturing are a few companies that have recognized the importance of reimbursement for their customers.

The final thing to remember about writing a Letter of Medical Necessity is to write it for a regular person. Most insurance reviewers have some medical knowledge, but are probably not familiar with every aspect of each disability and what it can mean in everyday life. All technical words and acronyms should be explained in the simplest of terms to allow the best understanding possible on the part of the reviewer. The goal is to make sure the insurance company understands they are affecting a person's real life by permitting or denying treatment.


For more information on how to write a Letter of Medical Necessity and other sample letters, consult the following resources:

Gaylord, Catherine & Levy, Anna L. Funding Care Coordination Services for Families of Children With Special Health Care Needs.

Center For Public Representation, March 1989.

Dr. John R. Bach

The Appeal Letter

Wyoming New Options in Technology

RESNA Technical Assistant Project

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Author:Henninger, Megan
Publication:The Exceptional Parent
Geographic Code:1USA
Date:Mar 1, 2003
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