LETTER 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]