Letters of Medical Necessity

The process of getting your insurance company to cover DME equipment is challenging and can feel overwhelming. Although daunting, with persistence and proper documentation, you can be successful.

Alternative and adaptive seating devices are becoming more and more visible to insurance providers, making the possibility of insurance reimbursements for these devices better than ever before. That being said, the standards for approval are also changing just as quickly, which makes preparation and documentation just as important as ever.

A letter of medical necessity is a document that you submit to your insurance company requesting coverage for a procedure or equipment. This letter describes why something is medically necessary for the treatment or rehabilitation of the beneficiary.

A letter of medical necessity includes the following:

  • explanation of the beneficiaries condition
  • description of the equipment
  • description of how the equipment addresses the condition
  • explanation of how the equipment can replace other expenses and is cost-effective

Insurers will generally not cover equipment for convenience, it must be medically necessary. Each insurer will have their own definition of medical necessity so you should review your policy to understand your insurers definition.

It is often helpful to have a physical evaluation and seating assessment performed in order to clearly describe why our chairs are  medical necessary.  This would include an evaluation of your condition and how our chairs can improve your condition.  You should also include long term benefits of using the equipment including how it can improve your condition and decrease future costs.

A letter of medical necessity is written by medical professional such as doctor or a licensed therapist. Some insurance carriers will require the letter come from a doctor. If a letter from a doctor is required, a letter from a PT, OT, etc., is good supporting evidence. Doctors and therapists often work together to prepare the documentation.

Many insurance companies will require a prescription in addition to the letter of medical necessity.  They may also require ICD codes.  You should also include a brochure for the equipment you are requesting. 

Below are links to a few articles that may be helpful to understanding and preparing letters of medical necessity.

Creating a Bulletproof Letter of Medical Necessity

The 4 Cs of Letters of Medical Necessity