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question

What is a letter of medical necessity?

Betty Long, RN, MHA
Betty Long, RN, MHA
Nursing
answer

A letter of medical necessity (aka LOMN) is an essential part of a request for services, and can be used in a wide range of issues.  Maybe a physician has ordered a new medication for a patient and the insurance company denies paying for the medication.  Or, a patient is hospitalized and his physician wants him to go to an acute rehab facility post discharge but the insurance company denies the request. Or, maybe a physician orders a piece of assistive technology (wheelchair, hearing aid, et al) and the insurance company decides they're not going to pay for it.    

A letter of medical necessity, whether being submitted to a private insurance company or other funding source, or a governmental agency like the Dept. of Human Services, should contain the information needed to convince the reader that the requested service is necessary to meet the medical needs of the person for whom the service is being requested.

In order to be effective, the letter of medical necessity should be written by a healthcare professional familiar with the requesting party's medical condition. The professional should briefly describe their credentials and relationship to the requesting party. This professional may be a physician, a nurse, a physical therapist, an occupational therapist or other medical professional. However, note that most funding sources (aka insurance companies) require a physician's prescription as part of the funding request. Therefore, letters of medical necessity not written by a physician should be endorsed by a physician or accompanied by a physician's prescription.

When an LOMN has been written, but services are still being denied, do yourself a favor and track it down so that you can make sure that the important parts are included.  Most LOMN are not that well written or compelling so insurance companies can easily deny the service.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.