How to ask your doctor for a letter of medical necessity

A letter of medical necessity is a letter from your treating doctor that explains why you need the care your plan refused. It is often the most important page in an appeal. Doctors’ offices are busy, so the best request is early, in writing, and complete: the denial notice, the plan’s reason, a date, and where to send the letter.

What this means

The appeal reviewer reads what is in the file. If the denial rests on a medical judgment, a letter from the doctor who treats you answers that judgment with a medical one. The letter says what your diagnosis is, what has been tried, why this care is needed and what is likely to happen without it.

Only your doctor can write those statements. They are the doctor’s professional opinion, in the doctor’s name. You cannot write them for the doctor, and this site cannot tell you what to say about your health. What you can do is make it easy for the office to say it.

Who does what:

• You: collect the papers, make the request, give the office a deadline, follow up, and send the letter on.
• Your doctor: reviews your records, decides what is medically accurate, and signs.
• The office staff: often draft, schedule and send. Ask who handles insurance letters.

What to do

1. Choose who to ask (your step). Ask the doctor who treats the condition that was denied, usually the specialist, and who knows your history. If more than one doctor treats you, ask the one who ordered the denied care.
2. Ask early. Ask as soon as you know there is a denial. The plan must give you at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls. Work backward from that date and give the office a send-by date well before it.
3. Hand over a short packet. Give the office the denial notice, any rule or guideline you have from the plan, the note to your doctor’s office and, if useful, the clinician letter on medical necessity. The note is a short cover page that tells the office what you are asking for and by when.
4. Say what the letter must answer. Point to the plan’s stated reason in the notice. A letter that answers that reason is more useful than a general letter of support.
5. Ask for records at the same time. Request your chart notes and test results from the office. See how to get your medical records.
6. Ask about a peer-to-peer call. Your doctor may be able to speak with the plan’s reviewing doctor. See peer-to-peer review.
7. Ask for the finished letter, a copy for you, and a note of when it was sent. Keep your copy. If the office sends it to the plan, ask for proof of when. Follow up a few days before your send-by date.
8. Add your own statement. The doctor covers the medicine. You cover what the condition does to your life. See writing your personal statement.

If the care is urgent

If a physician who knows your condition says the claim is urgent, the plan must treat it as urgent. A plan that is not grandfathered must defer to the attending provider’s decision. The doctor can also act as your representative in an urgent appeal. Ask the office to use the certification of urgency, and see how to get an expedited appeal.

What the office may say, and what to say back

“We already sent the plan our notes.” The reviewer reads what is in the file, and the plan must consider everything you send, including material the first reviewer did not see. Notes record what happened. A letter explains why it matters. Ask whether the doctor can write a short letter that answers the plan’s reason.

“We do not do appeals for patients.” You are doing the appeal. You only need the doctor’s letter and your records. Offer the note and the template so the office has less to do.

“The doctor does not have time.” Ask if staff can prepare a draft for the doctor to correct and sign. The doctor reviews every medical statement before signing.

“We cannot say that is necessary.” Ask what the doctor can say, and whether another doctor involved in your care can write. Do not push a doctor to sign something the doctor does not believe.

The rule

A plan must let an authorized representative act for a claimant, and in an urgent case must allow a health care professional who knows the claimant’s condition to act as the representative. When a physician with knowledge of the condition says a claim is urgent, the plan must treat it as urgent. See sections 2560.503-1(b)(4) and (m)(1)(iii) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.

Watch for

• Specific, not general. The Arthritis Foundation warns that appeals fail when they are incomplete, emotional or full of detail that does not matter. The same goes for the letter: it should answer the plan’s reason and stay on the facts.
• Your doctor’s voice. Do not draft the clinical facts yourself. Give the office the template and let the doctor fill in what is true.
• Different types of denial. A drug that needs another treatment tried first, or a use of a drug not listed on its label, calls for a different letter. See the step therapy exception letter and the off-label use letter.
• A letter is not a guarantee. It strengthens the file. It does not decide the result.

What next

• What a strong letter of medical necessity contains: what to look for in the draft.
• Peer-to-peer review and how to prepare your doctor: a call between your doctor and the plan’s doctor.
• How to write an appeal letter that works: where the doctor’s letter fits.