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The majority of insurance companies and other payors require a letter of medical necessity (LMN) to describe the medical necessity (not merely convenience) of the equipment and justify the purchase of all requested components. Most often these letters are generated by a physical therapist but may be written or signed by the physician. But keep in mind that the person reviewing such justifications may not be a therapist.
It is critical to demonstrate the purpose and/or function of the equipment for the student. Write the justification with an emphasis on functional ramifications of the recommended equipment. To write an LMN, we recommend that you follow the 4 Cs: be concise, clear, connected and contextual.
1. Concise – Focus on the priorities
Funded letters are well organized and put first things first! Most readers attend best to the first page of any document, the first sentence of a paragraph, the first item in a list,…So it is important to that the most critical information should be conveyed first.
Bulleted lists can keep information in order and as brief as possible. Don’t use a narrative paragraph when a phrase will do. Leave out elements that are not relevant to the use of the equipment. Then summarize and restate your main points in the last paragraph.
2. Clear – Be specific
The reviewer may not be a physical therapist or even a health professional; however, most reviewers are nurses. Write your letter assuming the reviewer knows nothing about the disability or the equipment. Educate the reviewer about your student, his/her needs and why this equipment is will address those needs.
Many of our students have complex diagnoses and complicated needs. Keep your letter focused on one issue at a time and don’t confuse the reviewer by jumping from issue to issue within the same sentence, paragraph or section; headings can assist with organization. Avoid abbreviations and technical jargon. Include your name and contact information for the reviewer and invite questions/opportunities to clarify need.
3. Connected – Describe use/function
Relate the child’s needs to the function of the equipment in concrete terms. Make connections as to how the equipment will afford improved access or independence. How will it overcome limitations of the disability? Did you compare the selected equipment with other options? How is it better than those options?
Often there are many components associated with the equipment. It is wise to include a list of the equipment and each component with a statement to justify the need and selection. For example:
- Invacare Orbit tilt-in-space wheelchair with 12” solid rear tires and 6” front casters –
- essential for pressure relief and access to feeding tube
- the seating system can be removed and fit onto a power base once student demonstrates capacity to operate power wheelchair
- this model will accommodate anticipated growth
4. Contextual – Provide a full picture
Reviewers typically do not know the child beyond what they read on paper. It is, therefore, your responsibility to furnish the reviewer a picture of the child using the selected equipment. Convey the child’s condition and how the equipment will meet the child’s needs in visual terms. Use photos or videos of the child using the equipment, if possible.
Describe the child’s habits and the family’s lifestyle to explain why certain equipment features are necessary (e.g., durability, tight turning radius). List the environment that the child frequents. For example, if ordering a wheelchair, mention ramps, door clearance, curbs, tight spaces such as the bathroom, school and classroom environment, etc. Why is the selected equipment the best fit for the child’s daily routine?
Equipment can also help minimize secondary impairment. Outline expected secondary impairments associated with the child’s condition. Will the equipment maintain current function? How will it reduce, ameliorate or correct the future impact of his/her disabilities?
Bottom line: inform the reviewer why this specific equipment with the listed components is a medical necessity for this student.
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Here’s How You Put the 4 Cs All Together
Consider including the following components in your LMN:
- Diagnosis and physical condition that apply to the equipment recommended
- Diagnosis and comorbidities (such as sequires, cardiopulmonary condition, etc.)
- Prognosis: How might the child’s condition change? Potential growth in height? Weight changes?
- Current or potential skin problem
- Overall posture and positioning requirements
- Motor function
- Contractures, range limitations that affect positioning
- Tone abnormalities, reflexive patterns, paralysis, weakness
- Functional limitations, required assistance
- Perceptual and cognitive function (if person is to independently mobile or operating a power wheelchair)
- Purpose of the equipment
- Current therapeutic and functional goals; how the equipment supports these goals
- Vocational benefits, if vocational rehabilitation is involved in funding
- Education benefits, if an educational source is funding
- Current access to home, school or community; will it improve with use of the equipment
- Improvement in independence, self-determination and self-reliance
- Comprehensive list of equipment needs
- Necessary components
- Justification for all components
- Price quote
- Selection process, including previous equipment
- What has been tried previously, and why it is no longer effective
- Information from other trials with other equipment
- Why equipment selected is the best fit for the child’s needs, environment and daily routine
Additional recommended items to include with LMN:
- Photo or video of student
- “Before” show student in current wheelchair or equipment – consider best view to demonstrate problem issues
- “After” to demonstrate student in selected wheelchair or equipment (or trials with loaned equipment)
- Include graphs or charts of equipment usage to demonstrate fluency and efficacy
- Demonstrate how the equipment selection process was comprehensive
- Describe team members involved in the selection (physician, therapists, family, teachers/other school staff, vocational educator/technician, Durable Medical Equipment specialist/vendor) and any information gathered by the team (observations or information collected from different locations)
- If possible, have members who participated in the evaluation sign the letter to demonstrate team involvement.
In case of denial…
I am shocked! If you followed the 4 Cs, the equipment should be on its way! However, if denied, find out why the request was denied and identify the steps to appeal this decision. Upon appeal, the request may be reviewed by a physical therapist. Address the concerns or questions raised by the denial with additional information, photos, videos or further justification. If you are requesting equipment from Medicaid, you should be aware of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) policy that is a part of every state’s Medicaid program.
Medicaid EPSDT Coverage
Medicaid provides for coverage of all medically necessary services that are included within the categories of mandatory and optional services listed in section 1905(a), regardless of whether such services are covered under the State Plan. These include physician and hospital services, private duty nursing, personal care services, home health, and medical equipment and supplies, rehabilitative services, and vision, hearing, and dental services. States must ensure that the full range of EPSDT services is available, as well as to assure that families of enrolled children are aware of and have access to those services so as to meet the individual child’s needs. The broad scope of services enables states to design a child health benefit to meet the individual needs of the children served by its Medicaid program—a benefit design that has the potential to result in better care and healthier children at a lower overall cost.
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Seeking Your Views
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