Restoring the ability to walk is a key step toward independence
Restoring the ability to walk is a key step toward independence

Tips for Writing Letters of Medical Necessity

View Sample Letters of Medical Necessity Here

In many cases your insurance company will pay for your Up n’ Go, but you will need to write a letter of medical necessity. Here are some tips on approaching an insurance company for coverage for your Up n’ Go.

Letters of Medical Necessity

The letter of medical necessity must explain why the patient needs the mobility system, and why none of the less costly systems (such as walkers) would work. The letter must be accompanied by a physical evaluation and a home evaluation.

As the beneficiary of your insurance, you are entitled to reimbursement for medical expenses. In order to get payment, you must prove that your loss should be covered and submit a claim to the insurer. The burden then shifts to the insurer to either pay or deny the claim. To deny a claim, an insurer must prove that your loss is clearly and unambiguously excluded from coverage under the written terms of the insurance policy.

In other words, if a medical insurance policy does not state that a medical expense is excluded from coverage, the expense is probably reimbursable.

You need to understand how your insurance policy defines medical necessity. Each individual insurance policy defines the term in a different manner and the same insurer might use different definitions of medical necessity in different policies. The definition of medical necessity is usually in the insurance benefits booklet, in the summary plan description. If you can not find it in your policy, call the insurance company and they will fax the relevant definition to you.

The goal of your letter of medical necessity is to get approval for the Up n’ Go so that you do not have to appeal an insurance claim denial. Although you will have an opportunity to appeal any denials, only a small percentage of denials are overturned.

Your letter must be geared to your audience. When you are describing your medical condition and the Up n’ Go, use only terms that an ordinary person who has never worked in health care would understand. The people who are reading your letter are not doctors.

Start with an outline

  • Opening sentence: state who you are and what you want and your condition.
  • Impact on your life — note your limitations and abilities without the equipment.
  • Discuss how limitations decrease your level of functioning.
  • Demonstrate how the equipment will increase your function and ability.
  • Describe the equipment — how it works and all the ways it will improve your functions.
  • Explain why it will work better to do this than alternatives.
  • Explain that the alternative may be counter-productive or cause a risk.
  • Explain how the equipment can replace other expenses, such as future medical stays, or is otherwise cost effective.
  • Bring up the insurer’s definition of medical necessity. State that the policy requires that the equipment meet certain criteria in order to be considered medically necessary. Provide a sentence explaining how each criteria is met.
  • In closing, make sure you depict the beneficiary as a real person who can better face a difficult adversity with this equipment. Make the person reading this never want to trade places with the beneficiary, but rather want to improve the beneficiary’s life by agreeing to pay for the equipment.

If the insurance company denies your claim, you can make an appeal. There is a time limit for filing an appeal, so you should do so immediately.

How to file an appeal for an insurance denial

Make sure you understand the specific reasons for the claim denial. The denial was based on specific reasons in the policy. You will need a good description of the policy and a copy of the benefits booklet. Your appeal needs to address the reasons for the denial. Most denials fall into three categories.

  • The denial may be based on a disagreement between physicians as to what is medically necessary.
  • The denial may be based on policy exclusion, such as a pre-existing condition.
  • The denial may have occurred because the policy did not specifically provide for coverage for a piece of equipment. In this case, so long as the equipment can fit into a general category of coverage, payment should be made.

If the denial is based on a disagreement between your physician and the insurance company’s physician, you must counter each point made by the insurer’s physician by providing medical evidence to the contrary. You may also want to get a second opinion.

If your claim was denied because of a policy exclusion, your must show that the Up n’ Go is outside of that exclusion. An example of this is when an insurance company denies coverage for a pre-existing condition. Your condition may not have been treated in the three months before the effective date of coverage, so the condition is not really pre-existing.

In evaluating whether a piece of equipment is excluded from coverage, it is often because that equipment is not the least expensive. When this occurs, you must show that the less expensive equipment will not help, and that the Up n’ Go can not be compared to a less expensive walker because there is so much more functionality with the Up n’ Go. If the denial is because there is no specific category for the Up n’ Go, the goal of the appeal is to find a coverage provision in the policy under which the equipment would fall and to demonstrate that the policy contains no relevant exclusion for the Up n’ Go.

In addition, you may have to submit a letter showing that you are authorized to file the appeal for the beneficiary. If you are thinking of filing a lawsuit to force the insurance company to pay for the equipment, you must submit any evidence you would like a court to consider when you appeal, and you must submit a testimonial from an expert.

Make sure your appeal is not late because the insurance company does not have to consider a late appeal and you will not be allowed to file a lawsuit.

Checklist for the Letter of Medical Necessity

  1. Have a copy of the insurance policy, a handbook, and the definition of medical necessity in that policy.
  2. Get the insurance company you are approaching to fax or email their definitions of medical necessity. Include it in your letter.
  3. Write the letter to your audience (remember they are not doctors).
  4. State who you are in the opening sentence.
  5. Explain beneficiary’s condition.
  6. Discuss the impact of the condition on the person’s life noting limitations without the adaptive equipment.
  7. Describe the equipment and explain how it will improve the beneficiary’s functions. Explain why alternatives won’t improve the beneficiary’s functions.
  8. Explain how the equipment can replace other expenses and is cost-effective.
  9. State how the insurance policy’s definition of medical necessity requires that the equipment meet certain criteria, and provide a one-sentence explanation of how each criterion is met.
  10. Close your letter by appealing to the person reading it, making the beneficiary a real person facing a difficult adversity that the person reading the letter can help.
  11. Enclose a copy of the prescription.
  12. Download and print out pictures of the product and include them with your letter.
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