Letter of Medical Necessity: What is it? Why do I need it? How do I write it?


First, a little background before we begin; I am a single mother of three. My oldest daughter is 19-years-old and diagnosed with PCDH19 (the umbrella for her severe autism, severe global delays, epilepsy, significant cognitive delays, non-verbal). She is a large, strong woman who also has significant behavioral challenges due to PCDH19. She is my lifetime guide and my shining light; I cannot imagine one day without her. My daughter comes with her share of challenges and it can be exceptionally difficult to navigate the special needs paperwork and red tape, especially when trying to improve her quality of life. My hope is that this blogpost will offer a proactive approach for you as you seek medical equipment for your children, and serve as a tool or a guide. I am in no way an expert in this field, this is what has worked for me and a few other families for whom I advocate.

What is a Letter of Medical Necessity?

A Letter of Medical Necessity (LMN) is exactly what it sounds like, a letter written by your physician stating why it is necessary for your child to have the medical equipment you are applying for. The letter contains no more than your child’s diagnosis – which I find, unfortunately, to be the norm from doctors. This is where your advocacy skills are needed on behalf of your busy doctor and your child. Who better to write the LMN for your physician than you anyway?!

Not only must the letter contain the full scope of the diagnosis, but it must also contain objective data (specifics outlined below) about your child’s condition, why your child’s current medical needs are not being met with the current medical equipment/methods, and the methods you have tried that prove that the current medical equipment/methods are failing. An LMN focuses on safety concerns, indicating that the medical equipment being applied for is required. Not even just a necessity.

Why do I need a Letter of Medical Necessity?

An LMN is a tool to utilize when applying for obscure things that insurance companies might not deem as a “requirement”. It serves as a cover letter to the packet of objective documentation your insurance carrier may require. They may dispute examples like, if your child is ambulatory, but you know they need a special stroller due to sensory integration issues and inability to walk in the community. Maybe your child requires a better bed with specific safety features that will help you keep them from eloping, keep safe during seizures, or banging their head against the wall with self-injury. Your child may be able to verbalize, but you know they require an augmentative device to function at full capacity. Having well-documented information directly relating to the medical equipment you’re applying for is the key.

How do I write a Letter of Medical Necessity?

In my opinion, the hardest part of writing the LMN is being able to break down the necessity and/or requirement enough so an insurance agent gets a realistic day-in-the-life without you turning your letter into a novel. You want your letter to be read. If they want to see more in depth then they have the opportunity to view your objective documentation. We seasoned parents know all too well about documentation – this is where your skills will shine!

Included in the LMN (see sample):

  1. Medical Diagnosis

  2. Bullet Points directly relating to the equipment requested

  3. Brief synopsis of the event(s) that requires the equipment

  4. All options tried before requiring the equipment

  5. Why the equipment is required – be specific to the elements of that equipment

Tips during writing:

  • Avoid using hypothetical scenarios such as “She may engage in self-injurious behavior if … and then it is a safety risk.” The statements need to read concise and strong. “She engages in self-injurious behavior that cause blunt force trauma to her head.”

  • Utilize “Caregiver” versus “Mom” or “Dad”; takes away emotional aspect

  • Focus on Safety

  • Keep the LMN easily read within 3 pages or less

  • Stay objective – fact based vs. opinion based.

Documentation that can be included with your LMN:

  1. Objective information (i.e., functional assessments, seizure or behavior logs that are tracked daily, state granted assessments, and/or any scale of measure to prove your child’s abilities or lack thereof, etc.)

  2. Photo(s) that directly relate to the safety issue from the current medical equipment (i.e., head injury, broken arm, etc.)

  3. Brochure with details about the medical equipment you are applying for

Sample Letter of Medical Necessity PDF

Final Thoughts:

As stated, this is an opinion-based blogpost based on my knowledge as a volunteer advocate for families. There is no magic equation as to why insurance accepts or denies requests, and it is a travesty the hoops we need to jump through to improve our children’s quality of life. On the bright side, you have made it this far and you are already a champion advocate! My biggest piece of advice as a seasoned mama – documentation (your best friend for the rest of your life)!

Julie

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The PCDH19 Alliance is a registered non-profit by the Internal Revenue Service under Section 501 (c)(3). We are 100% volunteer run. All the funds we raise go directly to funding research, supporting families, raising awareness, and finding a cure.

Copyright 2019 PCDH19 Alliance

926 A #212 Diablo Ave, Novato, CA 94947

EIN: 45-4020102

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