Letter of Medical Necessity: What is it? Why do I need it? How do I write it?
First, a little background before we begin… I am a single mother of three. My oldest daughter is 19-years-old and diagnosed with PCDH19 (the umbrella for her severe autism, severe global delays, epilepsy, significant cognitive delays, non-verbal). She is a large, strong woman who also has significant behavioral challenges due to PCDH19. She is my lifetime guide and my shining light; I cannot imagine one day without her. My daughter comes with her share of challenges and it can be exceptionally difficult to navigate the special needs paperwork and red tape, especially when trying to improve her quality of life. My hope is that this blogpost will offer a proactive approach for you as you seek medical equipment for your children, and serve as a tool or a guide. I am in no way an expert in this field, this is what has worked for me and a few other families I advocate for. Here’s an example that I’ve created for you to follow along with this guide...
What is a Letter of Medical Necessity?
A Letter of Medical Necessity (LMN) is exactly what it sounds like, a letter written by your physician and/or therapist stating why it is necessary for your child to have the medical equipment you are applying for. The letter should contain more than your child’s diagnosis. Unfortunately, medical providers often only provide the diagnosis and miss other important contextual information about the patient’s condition. This is where your advocacy skills are needed on behalf of your busy doctor and your loved one. Who better to write the LMN than you, anyway? Not only must the letter contain the full scope of the diagnosis, but it must also contain objective data (specifics outlined below) about your child’s condition: Why is your child’s medical condition not being met with the current medical equipment/methods? What are the methods you have tried and how do they prove that the current medical equipment/methods are failing? An LMN focuses on safety concerns, indicating that the medical equipment being applied for is required.
Why do I need a Letter of Medical Necessity?
An LMN is a tool to utilize when applying for less common things insurance companies might not deem as a “requirement” for your child’s life. It serves as a cover letter to the packet of objective documentation your insurance carrier may require. They may dispute examples like: If your child is ambulatory, but they need a special stroller due to sensory integration issues and inability to walk in the community. Maybe your child requires a better bed with specific safety features such as 360 degrees of padding, a secure enclosure and remote monitoring to stop them from wandering, keep them safe during seizures, and help with behaviors that result in self-injury. Your child may be verbal, but you know they require an augmentative device to function at full capacity. Having well-documented information directly relating to the medical equipment you’re applying for is the key to obtaining better products for their condition.
How do I write a Letter of Medical Necessity?
In my opinion, the hardest part of writing the LMN is being able to break down the necessity and/or requirement enough so an insurance agent gets a realistic day-in-the-life that isn’t a novel. These letters are a balance of objective data and emotional persuasion as it is a human on the other end reading them after all. If they want to see more in depth, then they have the opportunity to view your objective documentation. We seasoned parents know all too well about documentation – this is where your skills will shine!
How do I write my LMN for a special needs bed?
You will want to focus primarily on safety concerns and quantifying their impact, danger, and potential cost. From there, you can show how the unique features of the bed improve or completely remove those safety risks.
The tensioned canopy and safety zipper on the door of the Cubby Bed ensure that children with elopement, self harm issues, and those who may fall out of bed due to poor muscle tone are safe at night.
If your child has a tendency to become entrapped while they sleep, it is important to document that. The Cubby Bed’s safety sheets are a critical safety feature for many patients and exceed the 7 zone of entrapment guidelines set forth by the FDA. Many other beds do not have this which creates entrapment and suffocation risk.
The camera and recording feature is a good way for caregivers to be alerted if a child suffers a seizure in the middle of the night or has frequent safety issues. It also enables the caregiver to monitor the child's sleeping pattern and make any needed adjustments. Some insurance companies will say to have a baby monitor outside of the bed but this doesn’t provide good visibility and can be an additional safety risk with the camera unsecured and cords laying around.
It’s important to write specifically about your child’s needs that directly correlate to the advanced components of the Cubby Bed. There are cheaper options on the market that insurance may try to default to but the Boogaloo Bed has features that other beds don’t provide and provide incredible medical value.
The insurance agent needs to know that your child can benefit from a Cubby Bed specifically and why it is the only bed that meets all of your loved ones unique needs
You will also want to outline previous interventions that you have tried that have not worked or are too high risk. Insurance may suggest you try these before they will cover a bed so it’s important to be proactive in heading off those objections.
Common denial reasons and rebuttals:
- Install bed rails - FDA warns of entrapment risk
- Put the mattress on the floor - helps with fall risk but not other safety issues
- Add window/door locks - does not address all safety issues and can be a fire risk
- Use a baby monitor - does not address all safety concerns
- Use a helmet - can't sleep and does not address all safety concerns
- Increase medication - side effects, especially with other meds and can be seen as a chemical restraint
Here is the general structure of a LMN (see sample download below):
Bullet Points directly relating to the equipment requested
Brief synopsis of the event(s) that requires the equipment
- The results of the events (Did the child suffer injuries? Were they admitted to the hospital? Do you have expensive medical bills as a result?)
All options tried before requiring the equipment
Why the equipment is required – be specific to the elements of that equipment and how less costly alternatives have been ruled out
Tips during writing:
- Focus on safety concerns that will cost the insurance company money. They’d rather buy an expensive piece of equipment than pay for hospital visits or other safety costs. If you can quantify the costs of these safety risks with past bills, even better!
Avoid using hypothetical scenarios such as “She may engage in self-injurious behavior if … and then it is a safety risk.” The statements need to be concise and strong. “She engages in self-injurious behavior that causes blunt force trauma to her head.”
Utilize “Caregiver” versus “Mom” or “Dad”; takes away emotional aspect
- Keep the LMN easily read within 3 pages or less. Bullet points can help.
- Stay objective – fact based vs. opinion based.
(For more help please refer back to the example letter guide)
Documentation that is helpful to include with your LMN:
Objective information (i.e., functional assessments, seizure or behavior logs that are tracked daily, state granted assessments, and/or any scale of measure to prove your child’s abilities or lack thereof, etc.)
Photo(s) or video(s) that directly relate to the safety issue from the current medical equipment (i.e., head injury, broken arm, etc.)
Brochure with details about the medical equipment you are applying for
As stated, this is an opinion-based blogpost based on my knowledge as a volunteer advocate for families. There is no magic equation as to why insurance accepts or denies requests. The hoops we need to jump through to improve our children’s quality of life is heartbreaking. Even if you are denied, don’t worry. Many families get approved in the appeal process or you can look at alternative funding mechanisms such as grants, charities and foundations. On the bright side, you have made it this far and you are already a champion advocate! My biggest piece of advice as a seasoned mama – documentation (your best friend for the rest of your life)! Best of luck to you and your family!