LETTERS OF MEDICAL NECESSITY

One of the most important concepts in writing a letter of medical necessity is that the letter needs to go directly to the family before it is sent to the health insurance company, Medicaid or CHP+. It is the family's responsibility to review all the letters (primary care, specialists, therapists, the cover letter from the family, etc.) to be certain that the letters do not have conflicting information and that the language of the contract is understood by all writers. If a letter of a medical necessity is sent directly to the insurance company, you may find it neccesary to go to the second level of appeal without having the opportunity to fully present the case at the first level. Always request a photocopy of the insurance policy that describes the benefits and/or exclusions and other pertinent language (e.g. specific coverage codes). The following is a list of guidelines describing what needs to be included in a letter of medical necessity:

  • Name of the child, names of parents.
  • Date of birth of the child.
  • Insurance plan name (there may be more than one plan).
  • Relevant diagnosis.
  • Item/Service requested.
  • Why the item/service is medically necessary (refer to the plan's definition).
  • Identify positive/negative impacts that the item/service will providing (including the financial impacts as well as functional impacts).
  • Scope and duration of treatment.
  • Supplemental documents (letters from providers, research articles, product information, Parent Accessing resources, EPSDT Screen).
  • Funding sources NOT able to support child.
  • Terms to use: medically necessary, clinically- based, promoting independence, preventing secondary disability, cost-effective, safety, training period
  • Terms to avoid: custodial, rehabilitate, developmental delay/disability, speech delay (without a diagnosis such as aphasia) and long-term.

 

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