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Letter Of Medical Necessity Template: 7+ Examples & Samples {Free Word & PDF}


Letter of medical necessity banner

Someday, you may find yourself in a situation where your insurance company denies a service.

If you can present a Letter of Medical Necessity stating that treatment is crucial to your health, you can appeal to the insurance company.

To make your job easier, we have curated a few templates for situations that may require it.

Letters of Medical Necessity: Examples & Samples

These letters need to be thorough with all relevant information that the insurance company may need to decide. Request your healthcare provider to be as specific as possible with the details.

Please have a look at our examples and maybe even download some samples to get a better idea.

Letter of medical necessity printable pdf sample for therapy for insurance companies

FSA Example

You can turn to your FSA to pay for your condition. Even then, you will have to submit it to request the money. While making the appeal, you will have to fill in basic personal details. A medical practitioner is supposed to fill out the following:

  • Medical condition
  • Recommended treatment (with frequency and dosage)
  • Treatment duration
  • Print name of the practitioner
  • Signature of the practitioner
  • Date
Fillable FSA Example

HSA Example

Your Health Savings Account (HSA) is an account where you can save money on a pre-tax basis and later use it for medical expenditure. You can request this money with a LOMN that usually stays valid for a year.

If you want to use your HSA funds, your doctor’s note needs to mention the following medically necessary items on your letter:

  • Patient name
  • Diagnosis or condition
  • Recommended test, service, or treatment
  • How the treatment impacts the diagnosis
  • Signature of the provider
  • Date
HSA Sample

For Speech Therapy

Speech-language pathology and audiology are viewed as medical necessities since they are the treatments for impairment and not issues regarding the quality of life.

It would be helpful if you could ask your doctor to include these specific points in the LOMN.

  • Primary diagnosis name for the treatment being requested
  • Secondary diagnosis name specific to the condition
  • The severity of the symptoms the patient is showing
  • Written evaluation by an appropriate speech-language pathologist
  • Written treatment plan
  • Clinical information from a licensed professional
LOMN for speech therapy

For Dental Treatment

If your insurance company denies your claim for a dental service, you can ask your dental professional to provide a LOMN. It would be helpful if the letter contained the following.

  • Personal details of the patient
  • Insurance ID number
  • Date of service
  • Health history
  • Current diagnosis
  • Recommended treatment and duration
  • The medical rationale behind the recommendation
  • Tests or references
Sample for dental treatment

For Occupational Therapy

Here are a few essential components the therapist must include while writing an effective LOMN for occupational therapy.

  • Patient’s rehabilitation potential
  • Purpose of the therapy
  • The skill that will be achieved with the therapy
  • Specific, measurable goals with an estimated timeline
for occupational therapy

Printable PDFs

Here are a few things you should know about a LOMN.

  • Approval of the letter can take anywhere between days to weeks.
  • Understand the extent of coverage.
  • Be ready with all the supporting documents.
  • If your claim gets denied, appeal in a reasonable time frame.
Fillable letter of medical necessity Fillable LOMN

FAQs

Question: What is in a Letter of Medical Necessity?

A letter of medical necessity needs to include the following points to be appropriate.

Patient Identification

  • Patient’s name
  • Age of the patient
  • Insurance policy number

Physician Identification

  • Name of the treating professional
  • Relationship to the patient

Important Dates

  • When the letter was written
  • Last examination by the doctor writing the letter

Diagnosis

Recommended Treatment

  • Detailed description
  • Services
  • Medication

Duration

  • Preferably short duration

Medical history

  • Only relevant medical history (Click here for templates)

Summary

  • Logical rationale behind the services recommended
  • Why other services won’t work

Signature Of The Physician

  • Signature on the letterhead
  • Specialty
  • License number
  • Contact information

Supporting Information

  • Information on the drug
  • Relevant lab test results
  • Standard of care from the medical society
  • Supporting progress notes

Question: How do you start a Letter of Medical Necessity?

The first requirement to starting a LOMN is using the physician’s letterhead.

Here are a few tips you can follow to write it effectively:

  • Cite recent and relevant medical articles.
  • Mention past successes with the recommended treatment.
  • Reflect on previous ineffective treatment.
  • Detail the psychological factors relevant to your chosen treatment.
  • Mention conversations with other physicians or family members.
  • Include letters from consultants, such as occupational or physical therapists.
  • Address the methods suggested by the HMO.
  • Include information that an administrator may not know.

Question: Who provides a Letter of Medical Necessity?

Ideally, the LOMN should be written by a healthcare professional familiar with the patient’s medical condition.

It could be a nurse, an occupational therapist, a physician, a physical therapist, or any other medical professional. As long as it is a licensed doctor’s note (Check templates), you should be good to go.

Question: Can a patient write it?

Yes, a patient can write the LOMN. However, it will not be accepted unless a doctor makes it official.

It is the word of your healthcare provider that matters. They need to have some history with your case and write or review and sign on the letter.

Conclusion

We hope your search for a letter of medical necessity template ended here. You never know when the need for a LOMN arises. So, it’s best to be prepared with all the templates. This way, you can get done with the formalities in time and return to work soon.

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Sara Cemin

Hi, I am Sara Cemin and I’m all about designing meaningful stuff such as templates, Forms that are required in various activities of business and academics.I take a research-driven approach to cumulate the best templates on any topic,