Medical Justification

Medical Justification

A letter of medical necessity is required to obtain funding for equipment from an insurance provider. It is important that it is well-written and contains the necessary components required by most insurance companies. It not only sets up the possibility for approval and improves the speed of the process, but it can also lay the foundation for an appeal following a denial. The letter must be written by a medical professional and outlines why the adaptive equipment is medically necessary.

Letter of Medical Necessity Tips and Information to Provide:

Letter of Medical Necessity Structure:

Insurance providers want to know about the client’s diagnosis, specific impairments resulting from the patient’s diagnosis, and how the device will address or benefit the specific diagnosis and resulting impairments. The letter must include a written explanation of the diagnosis, along with the applicable code. It is very helpful in the approval process to describe how the patient’s impairments can be improved using the device or equipment you are requesting.

It is also very important to point out the long-term benefits. These benefits include:

  • Improved alignment, head control, breathing and pressure redistribution.
  • Improved proper hip abduction.
  • Increased pelvic stability.
  • Aids in passive stretching and a reduction in edema of the lower extremities.
  • Engaged opening of the airways.

You must include a description of the device, along with a justification as to why each accessory and feature is needed to meet the patient’s requirements. These accessories will be listed on the quote which will be provided by Freedom Concepts/Chill-Out Chair. A well-drafted letter of medical necessity should outline why an off-the-shelf purchase cannot be adapted successfully to meet the client’s needs, or what this piece of equipment offers that cannot be found elsewhere.

Remember that the insurance providers typically are looking for medical necessity. The letter must define the following points:

How does the piece of equipment do the following?

  • Addresses the client’s medical needs.
  • Improves the client’s impairments which are a result of the patient’s diagnosis.
  • Reduces the impact of the client’s physical or mental disability.
  • Restores the client’s best possible functional level or improves their capacity for normal activity.

The physician or therapist must adequately and medically justify why the equipment is necessary for the treatment or rehabilitation of the client. It should focus heavily on medical information and steer clear of any social, psychosocial and leisure benefits. It’s also imperative to include that the client has successfully trialed the product.

Obtaining the Letter of Medical Necessity:

Insurance providers require that all letters of medical necessity are written by a medical professional and signed by a physician that has seen the child in the last 6 months. This could mean that the letter of medical necessity is written by a physical therapist or occupational therapist and signed by the physician, or the physician may write a letter and additional supporting letters can be included by the physical and/or occupational therapist. The requirements may vary by your state. For this to be recognized by insurance providers, the primary medical provider must provide their name, title, clinic and facility information, their NPI (National Provider Identification) number and their signature on their documents.

Supporting letters of medical justification can be written by a Physical Therapist or Occupational Therapist. Any letter from a therapist must be accompanied by a short concurrence statement at the end of the letter from the primary medical provider. For this to be recognized by insurance providers, the primary medical provider must provide their name, title, clinic and facility information, their NPI (National Provider Identification) number and their signature.

Additional Information to Include:

A prescription for the adaptive equipment must be included. This prescription must be legible, clear and contain the following information:

  • Equipment requested.
  • Signature of the physician who wrote the letter.
  • State the ICD code(s) on the prescription.
  • Include the physician’s NPI number if they have one.

Sample Letters of Medical Justification:

Our Sales team has many years of experience working with families to medically justify our products. We would love to help get you on the right path to obtaining funding for your Chill-Out Chair. Please reach out to us if you have any questions or if you would like to obtain sample letters of medical necessity.

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