Letter of Medical Necessity (Durable Medical Equipment/Assistive Devices)

[Date]

[Payer/Plan Name]
[Payer/Plan Address]

Re: Letter of Medical Necessity / Prior Authorization Request

Patient: [Full name] | DOB: [DOB] | Member ID: [Member ID] | Claim/Reference #: [Claim/Reference #, if available]

Authoring Clinician: [Clinician name], [Credentials] | NPI: [NPI]
Practice: [Practice name] | [Address]
Phone: [Phone] | Fax: [Fax]

[To Whom It May Concern / Dear Medical Director]:

Device Request Summary

Requested Item(s): [Device name(s)] [HCPCS code(s) if known]
Manufacturer/Model: [Manufacturer/Model, or "To be determined after fitting"]
Quantity: [Quantity and units]
Duration of Need: [lifetime / >99 months / 12 months / 6 months / other] starting [Start date if relevant]
Primary Setting of Use: [home / school / work / community / facility]
One-Sentence Clinical Rationale: [Concise statement linking diagnosis → functional limitation → device benefit]

Executive Summary

[Primary diagnoses with ICD-10 codes] resulting in [core functional problem]. The patient experiences [key limitations and risks], and less intensive alternatives have [failed / are contraindicated / are insufficient for safety]. I am requesting [device] with [key features] to improve [specific MRADLs/ADLs or safety outcomes].

• [Key functional limitations impacting MRADLs/ADLs]
• [Failed or unsafe alternatives]
• [Requested device and essential features]
• [Expected functional/safety benefits]

Clinical Background

• Diagnoses (ICD-10): [Diagnosis 1 (ICD-10)]; [Diagnosis 2 (ICD-10)] (Include only diagnoses that directly justify the request)
• Onset and Course: [Acute / Chronic]; [Stable / Progressive / Intermittent]; [Date or timeframe]
• Impairments Driving the Request: [Relevant impairments: strength, endurance, ROM, coordination, balance, sensation, tone/spasticity, pain, skin integrity, respiratory/cardiac limitations, cognitive/visual factors]
• Anthropometrics: Height: [Height]; Weight: [Weight]; [Other sizing constraints if applicable]
• Prognosis and Duration of Need: [Improvement / Stability / Decline] expected over [timeframe]. [Rental vs purchase justification if applicable]
• Relevant Comorbidities: [Only if impacts device safety, sizing, or alternatives]

Current Functional Status and Safety Risks

• Mobility and Transfers: [Ambulation distance and assist level]; [Current device(s) used]; [Transfer method and assist level]; [Wheelchair propulsion ability if relevant]
• MRADLs/ADLs Impacted: [Toileting, bathing, dressing, grooming, feeding, household mobility — specify limitations and assistance required]
• Safety Risks: [Falls/near-falls: frequency, severity, timeframe]; [Pressure injury history: stage, dates]; [Caregiver injury risk]; [Other adverse events] (Include only documented events)
• Objective Measures: [Timed Up and Go, gait speed, 6MWT, Berg Balance, AMP/AMPPRO, wheelchair propulsion test, grip strength, ROM, wound staging, pressure mapping — include scores and dates if available]
• Patient/Caregiver Report: [Brief quote if it clarifies goals or barriers] (Do not substitute for clinical assessment)

Home Environment and Caregiving Context

(Include when device is mobility-related or coverage depends on home use)

• Residence Type: [Single-story / Multi-level / Apartment / Facility] with [entry access features]
• Access and Maneuverability: Doorways [widths]; Thresholds [heights]; Flooring [types]; Turning space [measurements]; Bathroom [layout]
• Feasibility of Use in Customary Locations: [Yes / No] — [Explanation]
• Caregiver Context: [Availability, capability, willingness] (If home evaluation is pending, state this rather than inferring access)

Alternatives Analysis

(Document prior treatments and less costly alternatives tried or considered)

Alternative	Trial Details	Outcome	Why Inadequate or Unsafe
[Conservative therapy / Cane / Walker / Rollator / Manual wheelchair / Off-the-shelf brace / Standard cushion / Other]	[Dates, duration, setting, supervision level]	[Response, adherence, adverse effects]	[Clinical rationale tied to exam/metrics; if not tried, state contraindication and label as clinician judgment]
[Alternative 2]	[Trial details]	[Outcome]	[Why inadequate or unsafe]

Requested Device and Feature Justification

(List each item separately; do not include features that are merely convenient)

• Base Device: [Device name] [HCPCS if known] — [Manufacturer/Model if required]
  Problem Addressed: [Impairments and MRADL/ADL limitations]
  Why Standard/Less Costly Option Is Inadequate: [Specific limitations or risks]
  Expected Benefit: [Function/safety improvement]
  Ability to Operate Safely: [Cognition, vision, coordination, transfer ability, postural control; caregiver capacity if applicable]
  Training and Follow-Up: [Plan for fitting, education, reassessment]

• Accessory/Feature: [Name] [HCPCS if applicable]; Quantity/Replacement: [Specify]
  Problem Addressed: [Description]
  Why Less Costly Feature Is Inadequate: [Description]
  Expected Benefit: [Description]

• Supply/Consumable: [Name] [HCPCS if applicable]; Quantity/Replacement: [Specify]
  Necessity for Device Function or Safety: [Description]

Expected Outcomes

(Frame as reasonable expectations supported by findings and prior trials)

• [Goal 1] within [timeframe] — [Metric or criteria for success]
• [Goal 2] within [timeframe] — [Metric]
• [Goal 3] within [timeframe] — [Metric]

Coverage Criteria Alignment

• Benefit Category: [DME / Prosthetic / Orthotic / Supply] — Meets plan definition: [Yes / No]
• Medical Necessity: Device addresses documented impairments and functional limitations: [Yes / No]
• Home Use Relevance: [Yes / No / N/A]
• Alternatives Tried or Contraindicated: [Yes / No]
• Ability and Willingness to Use Device: [Yes / No]; Training plan in place: [Yes / No]
• Expected Improvement in Function/Safety: [Yes / No]

Documentation Integrity

This letter is based on clinical evaluation dated [Evaluation date] and is consistent with the medical record. Supporting records and objective data are available upon request. [If information is pending, state pending items and anticipated completion date.]

Attachments

• [Recent visit note relevant to the condition]
• [PT/OT seating or mobility evaluation]
• [Objective test results: wound documentation, imaging, pulmonary function tests]
• [Home safety/access assessment]
• [Device trial documentation]
• [Prescription or order]

(Include only applicable items)

Closing

I am requesting authorization for [items with HCPCS if known] to address [specific functional limitations and safety risks] and improve [targeted MRADLs/ADLs and safety goals]. If additional information or a peer-to-peer discussion is needed, please contact me at [Direct phone].

Sincerely,

[Clinician name], [Credentials]
NPI: [NPI]
[Practice name]
[Address]
Phone: [Phone] | Fax: [Fax]
Date: [Date]