Free Sample Letter of Medical Necessity Template
Sample Letter of Medical Necessity
October 9, 2050
Floyd Cremin
Medical Review Officer
Portland, OR 97201
Dear Mr. Cremin,
I am writing to formally request a Letter of Medical Necessity for Jane Doe, who has been under my care since January 15, 2023. It is essential that this letter emphasizes the medical rationale for the treatment of severe asthma, which necessitates the use of a high-flow oxygen concentrator.
This treatment has been identified as a critical component of the patient's ongoing care plan, as it will significantly improve her quality of life and support her overall health outcomes.
Based on my clinical evaluation, Jane Doe has experienced frequent asthma attacks, difficulty breathing, and increased hospitalization, which are directly related to severe asthma.
The recommended intervention, a high-flow oxygen concentrator, is not only a medically appropriate option but also aligns with current clinical guidelines and best practices. Without this intervention, the patient may face further complications, including respiratory failure and potential hospitalization, which could lead to increased healthcare costs and reduced quality of life.
I urge you to consider this request seriously and recognize the necessity of this intervention for Jane Doe. Should you need any further information or clarification, please do not hesitate to contact me at [Your Email] or [Your Phone Number]. Thank you for your attention to this matter, and I look forward to your prompt response.
Sincerely,
[Your Name]
Physician
[Your Company Name]
