How to Write a Letter of Medical Necessity

Know The Goal – Explain To Health Plan

1. Why patient needs the service.
2. Consequence if service not provided.
3. That service is “medically necessary”.

Defining “Medical Necessity” – Covered Services That Are

1. Provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law.
2. To prevent disease, disability, or other adverse health conditions or their progression, or prolong life.

EPSDT Requirements – Members Under Age 21

All health care necessary to “correct or ameliorate physical and mental illnesses and conditions,” even if the service is not generally covered for adults.

What Should Be In A Physician’s Letter

1. Relationship with patient and recommendation authority
2. Patient’s exact diagnosis
3. Duration of patient’s condition
4. Patient’s functional limitations, capabilities, and abilities
5. Description of service/item being prescribed
6. Why requested services is MEDICALLY NECESSARY, either under general definition, or if member is under 21, under the EPSDT requirements
7. How use of service or item will allow patient to function independently and/or improve patient’s health
8. Anticipated limitations or health problems if service is not provided
9. An explanation of any other supporting rationale

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