What a strong letter of medical necessity contains

A strong letter of medical necessity answers the exact reason the plan gave for the denial, in your doctor’s voice, with facts the reviewer can check. This page is a checklist for you to read the draft against. Your doctor decides what is medically true. You check that the letter covers what the reviewer needs.

What this means

A reviewer who reads your file is asking one question: does this case meet our standard? A strong letter makes that question easy to answer. It tells the reviewer who the doctor is, what the condition is, what has been done, what the plan’s own rule requires, and how your records meet it.

The plan’s notice must state the specific reason for the denial and, for a medical necessity denial, either explain the clinical judgment or say the explanation is free on request. That reason is what the letter is answering. If you have the plan’s rule from a request, the letter can address it requirement by requirement. See how to find the insurer’s medical policy.

What to look for in the letter

Check the draft for each of these. Each one is the doctor’s to supply.

1. Who is writing. The doctor’s name, specialty, how long and in what role they have treated you, and contact details.
2. Which denial it answers. Your name, member number, claim number, the date of the denial, the service denied, and the reason the plan gave.
3. The diagnosis and current condition. Stated plainly, with the dates of key tests and results.
4. What has been tried and what happened. Earlier treatments, with dates, outcomes and reasons they stopped. The Patient Advocate Foundation’s appeals guide includes a template for a treatment or drug denial with a “tried and failed” section.
5. Why this care is needed. The reason in terms of your case, not only in general terms. For a Medicare Advantage plan, the plan must take into account your medical history, the physician’s recommendations and clinical notes, so the letter should be specific to you.
6. How it meets the plan’s criteria. If you have the plan’s rule, one short line for each requirement and the record that shows it.
7. The evidence. The guidelines, studies or approvals the doctor relies on, named so the reviewer can find them. See how to find clinical guidelines and studies.
8. What is likely without it. The doctor’s own view of the risk of going without, in medical terms.
9. Urgency, if it applies. Only the doctor can say the claim is urgent. A plan must treat a claim as urgent if a physician who knows your condition says so.
10. An offer to talk. A line saying the doctor is available for a peer-to-peer call, and how to reach the office. See peer-to-peer review.
11. The enclosures. A list of the records sent with it.
12. A signature and date. Signed by the doctor, not a staff member.

What to do

1. Give the doctor the plan’s reason and criteria (your step). Hand over the denial notice and anything from your claim file. That lets the letter answer the reason directly.
2. Read the draft against the list above (your step). Check that your name, dates and claim details are right. Do not change clinical statements. If something looks wrong or missing, ask the office.
3. Check tone and length. The letter should be factual and concise. The Crohn’s & Colitis Foundation’s tips for appeal letters are to state the purpose, give the identifying numbers and dates, and be concise and factual. The Arthritis Foundation notes that appeals fail when they are incomplete, emotional or over-detailed.
4. Match the plan’s words (your doctor’s step). If the plan says a drug is “experimental”, the letter should address that word and say what the doctor relies on. If it says “not medically necessary”, the letter should address the plan’s definition of that term.
5. Send it with the records. The letter goes in your packet with the matching records. See how to assemble and send an appeal packet.
6. Keep a copy and note the date. If the doctor sends it directly, ask for proof of when it was sent.

Letters for particular situations

• For a drug that needs another treatment tried first, use the step therapy exception letter.
• For use of a drug or treatment outside its labelled use, or a denial as experimental, use the off-label letter.
• For care outside the network, use the out-of-network necessity letter.
• For a fast decision, use the certification of urgency.
• For everything else, start with the letter of medical necessity.

What the plan may say, and what to say back

“The letter does not include enough clinical detail.” Ask which detail is missing, in writing, and ask your doctor to supply it. Send the answer as new evidence. The plan must consider material the first reviewer did not see.

“The letter is generic.” Ask your doctor to tie each statement to a date, a result or a record. A reviewer can check a fact. A reviewer cannot check a general statement.

The rule

For a Medicare drug plan exception, the prescriber must give an oral or written supporting statement: for a tiering exception, that the preferred drug would not be as effective or would have adverse effects, and for a formulary exception, that the requested drug is medically necessary for a listed reason. See section 423.578 of Title 42 of the Code of Federal Regulations (CFR): 42 CFR 423.578.

Watch for

• Medicare drug plans. The plan’s decision clock for an exception request starts when it receives the prescriber’s supporting statement. See Medicare drug plan appeals.
• Not a form letter. A template is a starting point. Your doctor should fill in every clinical blank with facts from your chart.
• Not advice. This page lists what a reviewer looks for. It is not medical or legal advice and does not predict an outcome.
• Your deadline. 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.

What next

• How to ask your doctor for a letter of medical necessity: getting the letter written.
• Writing your personal statement: your account of what the condition does to your life.
• How to write an appeal letter that works: where the doctor’s letter fits.