The letter of medical necessity, similar to the samples below, should be written and signed by your physician on his or her official stationery. These examples are not intended to be used verbatim and can be modified for use to describe any diagnosis and course of treatment.
Sample 1
To Whom It May Concern:
John Doe has been under my care for ___ years for the treatment of generalized intractable psoriasis. The patient has had psoriasis for many years, which has been recalcitrant to all standard treatment methods. His percentage of BSA is __%, and he has previously tried ___ and ___ with no success. He has used ultraviolet light therapy, and has had significant improvement. Therefore, it is medically necessary for Mr. Doe to continue to undergo treatment with ultraviolet light. This will probably need to be undertaken for several months at a time throughout his life to maintain a state of remission.
A home unit is necessary since treatment in a physician’s office would require a ___ hour round trip car ride to the closest center three times weekly. This would impose an unnecessary hardship on the patient, as his work schedule as ___ directly conflicts with the center’s hours of operation. Therefore, I am prescribing a Daavlin Narrowband UVB home phototherapy unit. This unit is FDA compliant, and has the same healing potential as the ultraviolet units used in psoriasis centers, but was designed specifically for home use. It is easy and safe for the patient to operate after proper instruction and continued monitoring by me.
If you have any questions, please do not hesitate to call me.
Sincerely,
John Smith, M.D.
Sample 2
To Whom It May Concern:
I am currently following Jane Doe. She is a patient with severe psoriasis, primarily of the arms and legs. This patient has had psoriasis for the past ___ years. Her percentage of BSA is ___% and she has previously tried ___ and ___ with little success. She has required a series of treatments with Narrowband UVB light, which was successful in clearing her psoriasis. The psoriasis has recurred and she has re-started her outpatient therapy. Because of the severity and extent of her skin condition, she will most likely require ultraviolet light therapy intermittently for the rest of her life.
That is why I have prescribed a Daavlin Narrowband UVB home phototherapy unit. This will allow her to be able to maintain a state of remission and get the treatment she needs. The unit is FDA compliant and is safe and easy to use under my consultation. Jane Doe’s work as ___ precludes regular visits to the psoriasis treatment center because of the hours of operation. I feel that it would be both in Ms. Doe’s best interest and cost effective for the insurance company if she were to be assisted in procuring an ultraviolet light source for home use.
I would be happy to forward any supporting material or answer and questions you may have.
Sincerely,
John Smith, M.D.