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How is ?medical necessity? determined? A doctor's attestation that a service is medically necessary is an important consideration. Your doctor or other provider may be asked to provide a ?Letter of Medical Necessity? to your health plan as part of a ?certification? or ?utilization review? process.
A letter of medical necessity is typically written by your healthcare provider and includes your diagnosis and duration of the treatment. It should also include the reason why the treatment, product, or service is needed. A letter of medical necessity does not guarantee that your expense will be approved.
This includes a brief description of the patient's diagnosis, the severity of the patient's condition, prior treatments, the duration of each, responses to those treatments, the rationale for discontinuation, as well as other factors (eg underlying health issues, age) that have affected your treatment selection].
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.
Tips for Requesting and Sending a Medical Necessity Letter Includes detailed identification for both patient and provider. Details the diagnosis, treatment, and relevant medical history. Explicitly affirms medical necessity and lack of a better or less costly alternative, citing supporting data and research if needed.