Letter of Medical Necessity
Often individuals are attempting to obtain products or equipment to assist in their care and recovery of neurological issues. If the item is specified in your insurance policy, the process of using a prescription from your healthcare provider is all that is needed.
If a particular medical supply, equipment, or treatment is not covered, you may still be able to obtain your request through a letter of medical necessity. This letter is written by your healthcare professional with information specifically about your health situation, why the request is being made, how it will affect your health, and information about the product or treatment being requested.
The health insurance policy number or Medicaid number must be at the top of the letter. Also, the owner of the policy is needed, whether it is you, a spouse, a parent, a guardian, or another. The policy owner’s address is provided in this section with the policy number.
Most companies have sample letters of medical necessity that have been used successfully. Samples are often readily available on company websites or through company contact. These letters need to be individualized to your specific needs. Modifications that make the need specific to your health are required.
Your healthcare professional may already have used some sample letters of medical necessity, so they are familiar with how to obtain them, but providing copies to your health professional is always welcome. Many companies will work with your healthcare professional to create the best letter.
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Once the letter is written, your healthcare professional sends it to the payor, however, the response from the payor will be sent to the owner of the policy that you provided at the top of your letter. Very often the first response from the payor will be negative. You will need to get that letter of response to the healthcare provider immediately as there will be a method of appeal that has a time limitation. Quickly giving the response letter to the healthcare professional allows them time to resubmit. Multiple resubmissions may be needed.
Payors contract with specific companies. You may submit a request for a particular brand of equipment or therapy site, however, the payor may have a contract with another company. You may eventually receive a positive response to your request, but it may be a similar piece of equipment or at another location for therapy.
Think through your request for equipment or therapy thoroughly. Use the suggestions of your therapists and nurses. For example, you may request a standing frame. Your initial request must contain all specifications as later modifications may not be allowed. You may require just the basic standing frame. If you will be transferring yourself into the standing frame, you may need a stronger material to support sliding on and off. Children will need equipment that grows with them. Gliders to use your arms to move your legs may be an option that will work to your benefit. Pressure-dispersing equipment is always needed. A self-pump for standing or an electrical lift option may make the device more independently useable. A tray attachment may be functionally helpful. Additions later added are usually not considered, so know upfront what you need.
The equipment or therapy provided may not look like what you have requested. Equipment used in a therapy setting is devised to be adjusted many times in one day to meet the needs of multiple individuals. At home equipment is provided to meet the needs of one individual. It is still extremely durable but not for community use. Therapy may be a bit different at another location. However, the goals and outcomes would be the same.