LETTERS OF MEDICAL NECESSITY
WHAT PROVIDERS NEED TO KNOW!
One of the most
important concepts in writing a letter of medical necessity that is least
understood is that the letter should never go directly to the insurance
company. The letter must go to the family contracted with the insurance company
so that they can coordinate this letter with all the other letters of medical
necessity for pre-authorization or appeal. It is the family’s responsibility to
review all the letters (primary care, pediatric specialists, therapists, the
cover letter from the family, service coordinators, etc.) to be certain that
the letters have no conflicting information and that the language of the
contract is understood by all writers (as explained above). The family often needs
to add product information regarding durable medical equipment, information
describing a procedure, pharmaceutical information or information regarding
standards of practice from recognized associations.
If a letter of medical
necessity is sent directly to the insurance company, one letter alone could set
off the need for a second level of appeal, without having the opportunity to
fully present the case at the first level.
If the family is
compiling all the letters, the therapist has the benefit of reviewing letters
from the prescribing physician before writing the therapy piece. Surprises
often show up in these letters, such as a verbal pledge of support by a
specialist turning into a letter withholding support after a potential call
from the health plan or another dissenting physician.
Always request a
photocopy of the policy language about benefits and/or exclusions and any other
pertinent language, such as codes. If a family would like to give a therapist a
sample letter that has served them in the past, it would be helpful to review
that information.
The following is a list
of guidelines of what to include in the letter of medical necessity:
1.
Name of the
child, names of parents (parent and child may have two different names)
2.
Date of birth
of the child
3.
Insurance plan
name (there may be more than one plan)
4.
Relevant
diagnoses (codes are helpful only if they are accurate and don’t conflict with
the exclusion language of the policy)
5.
Item/service
requested
6.
Why the
item/service is medically necessary (refer to the plan’s definition)
It can be helpful to
ask a person unfamiliar with the issues to review your explanation of medical
necessity to see if a person unfamiliar with therapy (such as an appeals person
at the insurance company) can clearly understand the precise reasons the
item/service is medically necessary. This is the heart of the discussion. If a
plan agrees that an item/service is medically necessary, but denies for other
reasons, such as “not a covered benefit”, your letter of medical necessity has
served it’s purpose.
7.
What the
positive/negative impacts the item/service will provide (including the
financial impacts as well as functional impacts)
8.
Scope and
duration of treatment
9.
Supplemental
documents (letters from other providers, research articles, product
information, PAR, EPSDT Screen)
10.
Funding
streams NOT able to support the child
11.
Terms to use:
a.
medically
necessary
b.
clinically
based
c.
promoting
independence
d.
preventing
secondary disability
e.
cost-effective
f.
safety
12.
Terms to
avoid:
a.
custodial
b.
rehabilitate
c.
developmental
delay/disability
d.
speech delay
(without a diagnosis such as aphasia)