Fillable Sample Letter Of Medical Necessity | HCP. IncyteCARES.com

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Sample Letter Of Medical Necessity | HCP. IncyteCARES.com

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SAMPLE LETTER OF MEDICAL NECESSITY
Payers may require prior authorization or supporting documentation in order to process and
cover a claim for the requested therapy. A prior authorization allows the payer to review the
reason for the requested therapy and to determine medical appropriateness. A patient-specic
letter of medical necessity will help to explain the physician’s rationale and clinical decision
making in choosing a therapy. Please see page 2 for a sample letter of medical necessity with
llable elds that can be customized based on your patient’s medical history and demographic
information and then printed. Please note that some payers may have specic forms that must be
completed in order to request prior authorization or to document medical necessity.
[Date]
[Contact Name of medical director or other payer representative]
[Contact Title]
[Name of Health Insurance Company]
[Address]
[City, State, Zip]
Re: Letter of Medical Necessity for [Product] [Strength]
Patient: [Patient Name]
Group/policy Number: [Number]
Date(s) of service: [Dates]
Diagnosis: [Code & Description]
Dear [Insert contact name or department] :
I am writing on behalf of my patient, [PATIENT NAME] , to
[REQUEST PRIOR AUTHORZATION/DOCUMENT MEDICAL NECESSITY] for treatment with [Product] .
[Product] is indicated for treatment of [Indication Statement] . This letter serves to document
that [PATIENT NAME] has a diagnosis of [DIAGNOSIS] and needs treatment with
[Product] , and that [Product] is medically necessary for [him/her] as prescribed. On behalf
of the patient, I am requesting approval for use and subsequent payment for the treatment.
Patient Medical History and Diagnosis
[PATIENT NAME] is a [AGE]-year-old [MALE/FEMALE] diagnosed with [DIAGNOSIS] .
[NAME OF PATIENT] has been in my care since [DATE] . As a result of [DIAGNOSIS] , my
patient [ENTER BRIEF DESCRIPTION OF PATIENT HISTORY] .
Additionally, [PATIENT] has tried [PREVIOUS THERAPIES] and [OUTCOMES] . The
attached medical records document [PATIENT NAME] ’s clinical condition and medical necessity for
treatment with [Product] .
Based on the above facts, I am condent that you will agree that [Product] is indicated and medically
necessary for this patient. The plan of treatment is to start the patient on [Product] , monitor platelet
count and response to therapy and adjust dose accordingly.
Please consider coverage of [Product] on [PATIENT NAME] ’s behalf, and approve use and
subsequent payment for [Product] as planned. Please refer to the enclosed Prescribing Information
for [Product] . If you have any questions regarding this matter, please do not hesitate to call me at
[PHYSICIAN TELEPHONE NUMBER]. Thank you for your prompt attention.
Sincerely,
[PHYSICIAN NAME] , <DEGREE INITIALS>
[PROVIDER IDENTIFICATION NUMBER]
Enclosures:
Prescribing Information (PI)
[Clinic notes & labs] <If applicable>
MAT-INC-00488
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Sample Letter Of Medical Necessity HCP. IncyteCARES.com

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Completed 26 July 2021

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