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Letter of Medical Necessity Template
A letter of medical necessity explains why your patient needs a specific item, drug, or service, for a health plan’s review or an HSA or FSA claim. Tie each reason to a finding in the chart, answer the plan’s criteria one by one, and attach the records that show it.
For clinicians in the United States.
- Free, no account needed
- Word and text downloads
- Two filled examples
Blank letter of medical necessity template
FreeLETTER OF MEDICAL NECESSITY [Practice name] [Address] [Phone and fax] NPI: [Number] Date: [Date] To: [Health plan's utilization review or appeals department, or the HSA or FSA plan administrator] [Address, fax, or portal] Re: [Patient's full name] Date of birth: [Date] Member ID: [Number] Group number: [Number] Claim, reference, or authorization number: [Number, or new request] Type of request: [Prior authorization, appeal of the denial dated ..., or HSA or FSA eligibility] Item or service: [Name, quantity, and frequency] Code: [HCPCS or CPT code] Diagnosis: [Diagnosis and ICD-10-CM code] Dear [Medical director, reviewer, or plan administrator], I am writing to request [coverage or reimbursement] of [item or service] for my patient, [patient name], whom I have treated since [date] for [condition]. Diagnosis and history: [When the diagnosis was made, and the findings and results that support it, with dates] Treatments tried: [Each treatment, with dates, dose or frequency, and the result or the reason it was stopped] Functional impact: [What the condition stops the patient doing, and the risk if it goes untreated] Why this item: [How it treats the condition, and why each alternative is not suitable for this patient] Plan criteria: [Each criterion in the plan's policy or denial letter, and the finding that meets it] Evidence: [The guideline, plan policy, or study you rely on, with its year] Expected outcome: [The goal, how you will measure it, and when you will review it] Duration of need: [Start date, and how long, e.g. 12 months or long term] In my clinical judgment, [item or service] is medically necessary for [patient name]. My records support this, and copies are attached. Attached: [Visit notes, test results, logs, the denial letter, and the plan policy] Please contact me at [phone or email] for a peer-to-peer review or more information. Sincerely, [Your name, credentials] [Specialty and license number] [Signature]
Use it for
- Prior authorization
- Appeals of denied claims
- HSA and FSA claims
- Medical equipment and supplies
- Drugs and step-therapy exceptions
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Letter of medical necessity: continuous glucose monitor appeal
Family physician to a commercial health plan, first-level appeal
Request
Appeal of the denial dated October 6, 2026. I request coverage of a continuous glucose monitor and monthly supplies, HCPCS E2103 and A4239, for a 54-year-old man with type 2 diabetes with hypoglycemia, E11.649, on long-term insulin, Z79.4.
The plan’s criteria
The denial letter quotes the plan’s policy: insulin treatment with 3 or more injections a day or a pump, and documented hypoglycemia. It states that the records sent did not show his insulin regimen. He meets both criteria, as shown below.
Diagnosis and history
Type 2 diabetes since 2014. On multiple daily injections since March 2026: insulin glargine 32 units at bedtime and insulin lispro 6 to 10 units with each meal, 4 injections a day. A1c 8.4% on September 15, 2026.
Low glucose episodes
His meter log for August 10 to October 4, 2026 shows 7 readings below 70 mg/dL, 2 of them below 54 mg/dL. One was at 3 a.m. on September 22, when he woke sweating and shaky and treated it himself with juice.
Treatments tried
Fingerstick testing 4 to 6 times a day since March 2026. Glargine reduced from 36 to 32 units and the dinner lispro dose lowered on August 18, 2026. Hypoglycemia education with our diabetes educator on September 1, 2026. The lows continued, and fingersticks can’t warn him while he sleeps.
Why this item
He works as a forklift operator and has stopped work twice this fall to treat a low. A monitor with low-glucose alerts lets him treat a falling glucose before it becomes severe, and lets us adjust his insulin safely. More fingersticks would not detect lows overnight.
Evidence
The American Diabetes Association’s Standards of Care in Diabetes recommend continuous glucose monitoring for adults with diabetes on multiple daily insulin injections.
Outcome and duration
Goals: no readings below 54 mg/dL, and a lower A1c without more lows. I will review his monitor data in 3 months and at each visit after. Needed long term, while he is on insulin.
Attached
Meter log for August 10 to October 4, 2026; visit notes from August 18 and October 13, 2026; medication list; the denial letter.
Letter of medical necessity: medically supervised weight-loss program
Primary care physician, for the patient’s FSA claim or HSA records
Request
To the plan administrator: I recommend a medically supervised weight-loss program for my patient, a 47-year-old woman, as treatment for obesity and hypertension that I have diagnosed.
Diagnosis
Obesity, class 2, E66.812: weight 98.3 kg (217 lb), height 165 cm, BMI 36.1 on October 14, 2026. Essential hypertension, I10, diagnosed in 2023: BP 146/92 and 144/90 at her last two visits, on lisinopril 20 mg daily.
Treatments tried
3 visits with a registered dietitian in 2025, and a home walking plan. She lost 3 kg (7 lb) over 6 months and had regained it by June 2026.
Recommended treatment
Enrollment in a medically supervised weight-loss program, with weekly group sessions and monthly visits with the program’s clinician. Goal: a 5 to 10% weight loss and lower blood pressure. I will review her weight and blood pressure every 3 months.
Duration
12 months, from October 26, 2026.
What this letter covers
The program’s fees. It does not cover gym membership dues or food.
What the official sources say. Checked October 2026.
A letter supports a request; the plan decides it. These sources set what a letter can and can’t do for HSA and FSA expenses and Medicare equipment claims.
Weight loss under an HSA or FSA
Amounts paid to lose weight count as medical expenses only if the weight loss treats a specific disease diagnosed by a physician, such as obesity, hypertension, or heart disease. Gym, health club, and spa membership dues don’t count, but separate fees charged there for weight-loss activities can.
What HSAs and FSAs cover
HSA qualified medical expenses are amounts paid for medical care as defined in Code section 213(d). For a health FSA, they are the expenses specified in the plan that would generally qualify for the medical and dental expenses deduction.
Medicare equipment: the record
Supplier-prepared statements and physician attestations by themselves don’t provide sufficient documentation of medical necessity, even if signed by the ordering physician. The beneficiary’s medical record must support the need for the type and quantity of items ordered.
Medicare equipment: certificates
CMS stopped using certificates of medical necessity and DME information forms for claims with dates of service on or after January 1, 2023.
What goes in each part.
Patient and request
Who the patient is, which plan, and exactly what you are asking for, so the letter is matched to the right case.
- Patient name, date of birth, member ID, and group number
- The claim, reference, or authorization number, if there is one
- The item, drug, or service, with its HCPCS or CPT code, quantity, and frequency
- The type of request: prior authorization, an appeal, or HSA or FSA eligibility
Avoid: A vague item like “supplies” or “therapy”. Name the item and the code the claim will use.
Diagnosis and history
The condition the item treats, and the evidence for it, with dates.
- The diagnosis and its ICD-10-CM code, matching the claim
- When it was diagnosed
- Examination findings, test results, and measurements, with dates
- Other conditions that bear on the request
Avoid: A diagnosis with no findings behind it. Reviewers look for the result that confirms it.
Treatments tried
Many plans want to see that standard or lower-cost options came first, especially for drugs with step therapy.
- Each treatment, with dates, dose, or frequency
- The result: no response, a partial response, side effects, or a contraindication
- Why it was stopped
Avoid: “Failed conservative treatment” with no detail. Say what, when, for how long, and what happened.
Why this item
The heart of the letter: how this item treats this patient’s condition, and why the alternatives won’t do.
- What the condition stops the patient doing, and the risk if it goes untreated
- How this item addresses it
- Why each alternative is unsuitable for this patient
- Each criterion in the plan’s policy or denial letter, and the finding that meets it
Avoid: Arguing convenience or preference. Plans approve treatment for a condition.
Evidence, outcome, and duration
What supports your choice, what you expect it to achieve, and how long the patient needs it.
- The guideline, plan policy, or study you rely on, with its year
- The expected outcome, and how you will measure it
- The start date, and how long it is needed: a set period or long term
- When you will review it
Avoid: Leaving out the duration. An approval or reimbursement may cover only the period you state.
Signature and attachments
The letter points to your records; it doesn’t replace them.
- Your name, credentials, NPI, and a number for a peer-to-peer review
- Your signature, and the date
- Visit notes, results, and logs, plus the denial letter if you are appealing
Avoid: A letter your notes don’t back up. For Medicare equipment claims, a signed statement by itself isn’t enough.
Common mistakes, and how to avoid them.
A letter the chart doesn’t support
Reviewers compare the letter with your notes. Write the findings into the visit note first. For Medicare equipment claims, the medical record has to show the need, not the letter.
Not answering the plan’s criteria
Get the plan’s medical policy, or the denial letter, and answer each criterion in turn with a finding and a date.
“Medically necessary” with no reasons
The phrase alone proves nothing. Give the diagnosis, what was tried, and why this item is needed now.
Wrong codes or IDs
Check the member ID, the HCPCS or CPT code, and that the ICD-10-CM code fits the item. A mismatch can send the request back.
Promising tax treatment
For HSA or FSA items, describe the diagnosis and the treatment. Don’t write that the expense is eligible: the plan administrator decides.
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Frequently asked questions.
What is a letter of medical necessity?
A letter from the treating clinician that explains why a patient needs a specific item, drug, or service. Health plans use it for prior authorization and appeals, and HSA or FSA administrators may ask for one when an expense could also be for general health.
What should a letter of medical necessity include?
The patient’s plan details, the item with its HCPCS or CPT code, and the diagnosis with its ICD-10-CM code. Then the history and results with dates, the treatments tried, the functional impact, why alternatives won’t work, the evidence, the expected outcome and duration, your signature, and the records attached.
How do I write a letter of medical necessity for an insurance appeal?
Get the denial letter and the plan’s medical policy. Quote each criterion and show the finding, result, or date that meets it. Attach the records, and offer a peer-to-peer review.
When does an FSA or HSA need a letter of medical necessity?
When an expense counts only if it treats a specific condition, a letter shows that it does. IRS Publication 502 includes weight-loss programs only when they treat a specific disease diagnosed by a physician, and supplements only when a medical practitioner recommends them to treat a condition diagnosed by a physician. The plan administrator decides what it reimburses, and what proof it needs.
Can a letter of medical necessity cover a gym membership?
IRS Publication 502 says gym, health club, and spa membership dues can’t be included as medical expenses. It does allow separate fees charged there for weight-loss activities, when the weight loss treats a specific disease diagnosed by a physician. The plan administrator decides what it pays for.
How long is a letter of medical necessity valid?
It depends on the plan. State the start date and how long the treatment is needed, and tell the patient to check whether the plan wants a new letter each plan year.
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Does Medicare accept a letter of medical necessity?
For equipment claims, Medicare’s DME contractors say supplier-prepared statements and physician attestations by themselves don’t provide enough documentation of medical necessity, even when the ordering physician signs them. Your medical record has to support the need for the item and the quantity, so put it in your visit notes.
Is this letter of medical necessity template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
Can Vero write a letter of medical necessity from my visit?
Yes. Vero drafts the letter from your visit note in your template. Review it against the plan’s criteria, edit it, then export it to PDF or Word, print it, or email it.
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