Insurance denies a service. It’s happened to us all. We call, write letters and shout into the void, ultimately taking the loss. But there is a tool – a potent tool – for getting treatments or tests covered by your insurance: The Letter of Medical Necessity.
WHAT IS THE LETTER OF MEDICAL NECESSITY?
Simply put, insurance has an interest in denying expensive test and treatments. But those services may be the best or only thing that can advance your care. Your doctor says you need this treatment, but your insurance says you don’t. Get your doctor to write a letter of medical necessity (“LOMN” – we need an acronym here). The LOMN is the formal argument made by your doctor to cover a certain test or treatment because that specific test or treatment is the only one that is right for you. It’s not a gentle suggestion, it’s a legal document that says, ‘in my professional medical judgement patient x needs treatment y’.
CAN A PATIENT WRITE IT?
A patient can write the letter, but it needs to be made official by a doctor. Any arguments for any service ultimately have to come from a treating physician. That means the doctor needs to know you, have some history with you, and in the end either write or ‘sign off on’ the letter.
MEDICAL NEED
The LOMN must show medical need. For instance, the service in question will (or is reasonably expected to)
- prevent the onset of an illness or a disability
- reduce or improve the effects of an illness or disability
- achieve (or maintain) the maximum functional capacity of the specific patient in performing daily activities given age and baseline functionality. In other words, ‘without this my patient can’t do stuff other people like them can do’.
WHAT DOES THE LETTER OF MEDICAL NECESSITY NEED TO INCLUDE?
PATIENT IDENTIFICATION:
name, date of birth, insured’s name, policy number, group number, (Medicare or Medicaid number) and date letter was written.
PHYSICIAN IDENTIFICATION:
name of treating physician and relationship to the patient (“I am Jim’s endocrinologist”).
DATE OF MOST RECENT EVALUATION:
when you were last examined by the doctor writing the letter
DIAGNOSIS:
The diagnosis that has led to the medical need must be very specific. For example, “back pain” is not specific; “lumbar spinal stenosis with herniated disc at L3” is specific. This should also include date of diagnosis.
TREATMENT:
The recommended treatment must be named and described in detail. “calcium supplementation” is not specific; “800 IU of Vitamin D and 1200 mg of Calcium supplements each day by mouth for the next 6 months to alleviate symptoms of hypocalcemia” is.
DURATION OF TREATMENT:
Your provider must state a specific length of treatment. Lifetime or indefinite lengths of treatment will not be approved. When a treatment must be continued for a long period of time you should expect to have to renew the letter of medical necessity periodically.
PERTINENT MEDICAL HISTORY:
history unrelated to the medical need only bogs down the letter. Stay on message. A diagnosis of, say, Ehler’s Danlos Syndrome would include all of the primary symptoms, treatments previously attempted and what the results of those attempts were. This should include related ER visits, hospitalizations, medical procedures, etc. If previous treatments failed or were not tolerated, this should be mentioned.
MEDICAL NECESSITY:
Why is this treatment medically necessary? How will it prevent, diagnose, or cure conditions in the patient that endanger the patient’s life, cause suffering, pain, physical deformity or malfunctions, or threatens to cause a handicap. It is equally important to say that there is no equally effective treatment available which is more conservative or less costly.
SUMMARY:
An brief, logical final argument. Rhetorically speaking, this should leave no holes or alternatives to the medically necessary treatment.
SIGNATURE:
the treating physician’s signature on their letterhead, including their specialty, license number, and contact information.
SUPPORTING LITERATURE:
If applicable, the LOMN should include the following as a supplement or appendix:
- A drug’s full Prescribing Information
- Relevant medical literature regarding the use the treatment for the patient’s specific diagnosis
- Standard of care from medical society
- Peer reviewed publications
- Supporting lab/test results
- Supporting progress notes
YOU HAVE THE LETTER, NOW WHAT?
A copy of the letter should go into the patient medical record. The patient should also have a copy. This LOMN will be vital if an appeal should become necessary.
You will need to find the correct address to send the Letter of Medical Necessity. Each insurer is different. You may find the medical secretary, nurse or medical assistant in the doctor’s office helpful here.
APPEALS
The letter of medical necessity is a LEGAL document and patients need legal support against giant corporations that want to spend as little as possible on care. It is the formal medical judgement of a licensed physician as to why a patient needs a specific treatment and why other treatments are not appropriate. An insurer may still deny the treatment, but the LOMN is your best chance at getting approved. It becomes even more powerful when an appeal is made because your doctor can then respond to the notes made by the insurer.
Jim Sliney Jr. is a Registered Medical Assistant and a Columbia University trained Writer/Editor. He creates 
education and advocacy materials for patient support groups. Jim has worked closely with several rare disease communities. He also coordinates the patient content for Patients Rising and collaborates with other writers to hone their craft. Jim is a native New Yorker where he lives with his wife and all their cats. Connections: Twitter Email
note: background image, “Allegory of Victory” by Jules Joseph Lefebvre
