Letter of Medical Necessity: What is it? Why do I need it? How do I wr

By Julie Wismann

First, a little background before we begin; I am a single mother of three. My oldest daughter is 19-years-old and has been diagnosed with PCDH19 (the umbrella for her severe autism, severe global delays, epilepsy, significant cognitive delays, nonverbal). She is a large, strong woman with substantial behavioral challenges due to PCDH19. She is my lifetime guide and shining light; I cannot imagine one day without her. My daughter comes with her share of challenges. It can be challenging to navigate the special needs paperwork and red tape, especially when improving her quality of life.

I hope that this blog post will offer a proactive approach for you as you seek medical equipment for your children and serve as a tool or a guide. I am not an expert in this field. This method has worked for me and a few other families I advocate for.

What is a Letter of Medical Necessity?

A Letter of Medical Necessity (LMN) is just what it sounds like: A letter written by your physician stating why your child must have the medical equipment you are applying for. The letter contains more than your child’s diagnosis – which I find, unfortunately, the norm from doctors. This is where your advocacy skills are essential for your busy doctor and child. Who better to write the LMN for your physician than you anyway?!

The letter must contain the full scope of the diagnosis, but it must also include objective data (specifics outlined below) about your child’s condition. It explains why your current child’s medical condition is not being satisfied by the current medical equipment/methods. The methods you have tried prove that the current medical equipment/methods fail. An LMN focuses on safety concerns, indicating that the medical equipment you are applying for is required. Not even just a necessity.

Why do I need a Letter of Medical Necessity?

Having well-documented information relating to the medical equipment you’re applying for is the key. An LMN is a tool to utilize when applying for obscure things that insurance companies might not deem as a “requirement .” It serves as a cover letter to the packet of objective documentation your insurance carrier may require.

The insurance company may dispute the request. For example, if your child is ambulatory, but you know they need a particular stroller due to sensory integration issues and inability to walk in the community. Maybe your child requires a better bed with specific safety features that will help you keep them from eloping, stay safe during seizures, or from banging their head against the wall, preventing self-injury. Your child may be able to verbalize, but you know they require an augmentative device to function at full capacity. You know your child best, but your testimony cannot stand alone. The Letter of Medical Necessity provides documentation to the insurance company that supports your request for equipment, increasing your chance for approval.

How do I write a Letter of Medical Necessity?

Image: Cottonbro Pexels

You want your letter read. As seasoned parents, we know all too well about documentation. This is where your skills will shine! The most challenging part of writing the LMN is breaking down the necessity and/or requirement enough, providing a real day-in-the-life account without you turning your letter into a novel. Remember: If they want to see more in-depth, they can view your objective documentation.

Included in the LMN (see sample):

Medical Diagnosis
Bullet Points directly relating to the equipment requested
A brief synopsis of the event(s) that requires the equipment
A list of all exhausted options before requiring the equipment
Why the equipment is necessary – be specific to the elements of that equipment

Tips during writing:

Avoid using hypothetical scenarios such as “She may engage in self-injurious behavior if … and then it is a safety risk.” The statements need to read concise and strong. “She engages in self-injurious behavior that causes blunt force trauma to her head.”
Utilize “Caregiver” versus “Mom” or “Dad”; takes away the emotional aspect.
Focus on Safety
Keep the LMN easily read within three pages or less
Stay objective – fact-based vs. opinion-based.

Documentation to include with your LMN:

Objective information (i.e., functional assessments, seizure or behavior logs that are tracked daily, state-granted assessments, and/or any measurement scale to prove your child’s abilities or lack thereof, etc.)
Photo(s) that directly relate to the safety issue from the current medical equipment (i.e., head injury, broken arm, etc.)
Brochure with details about the medical equipment you are applying for

Final Thoughts:

As I mentioned before, this is an opinion-based blog post based on my knowledge as a volunteer advocate for families. There is no magic equation for why insurance accepts or denies requests, and it is a travesty of the hoops we need to jump through to improve our children’s quality of life. On the bright side, you have made it this far, and you are already a champion advocate! My most significant piece of advice as a seasoned mama – documentation (your best friend for the rest of your life)!

Julie