Patient Letter of Medical Necessity Sample with Examples

This Patient Letter of Medical Necessity describes the patient’s medical condition, what treatment is proposed, and then the reason this intervention is recommended as a for the patient’s .

This usually means a comprehensive description of why the current treatment directly relates to the results of the diagnosis and the way it will greatly improve their level of living and prevent more issues. It is a letter or message that gives insurers or any other interested parties a full picture of just why the medical care is so important so that the patient gets what they need in his or her plan of treatment.

Sample Patient Letter of Medical Necessity with Examples

Medical Treatments

• Patient Letter of Medical Necessity is written to insurance companies explaining the clinical necessity of any treatment, service or device and how is it necessary for a patient to use; particularly if in case the insurance is to cover the service or device.

Assists with Insurance Claims Documentation

• The report can also help with insurance claims as it establishes the medical justification for any given treatment and its role in the patient’s recovery, which can beat back denials from insurance companies.

Ensures Care Is Specific to Each Patient

• By outlining the patient’s specific condition and the needed treatment, the letter helps ensure care is delivered to the patient, not generic or one-size-fits-all.

Even More Access Negotiation to Specific Treatments

• The letter is specific to access to specialized treatments, trials or rare drugs that are not guaranteed from insurers, deepening the negotiation process around the specific case of the patient himself.

Prevents Delays in Treatment

• The letter, in tandem with formal documentation, paves the way for the insurance process to be expedited, and this can save the patient months of time to receive the treatments they require.

Legally Defensible

• In the event that patients run into a problem with their insurers, this letter carries legal weight in favor of the patient and his/her need for the proposed medical interventions, making appeals and negotiations that much stronger.

It states medical necessity

• The letter defines medical necessity — why the treatment or service is medically necessary, how the intervention is based on and/or meets a long- or short-term need related to the patient’s health, and how it prevents worsening or deterioration of the patient’s condition.

Encourages Communication

• The letter serves as a two-way means of communication between your health care assets, your patient and the insurer that ensures that each party’s playing in the same ballpark on the need for the recommended medical care.

Advocate for the Patient’s Rights

• It is an essential advocate for the patient, defending that person’s right to access medically necessary services, making sure that care is being provided based on medical necessity as opposed to financial or bureaucratic interests.

Builds Patient-Physician Trust

• According to the letter, the doctor is their advocate, obtaining the best treatment option possible for their condition, creating greater trust and cooperation between him (or her) and his or her provider.