Most people believe that getting insurance approval for medical treatments is entirely up to your doctor’s recommendation. This couldn’t be further from the truth. Your insurance company makes the final decision, and they base that decision largely on one document you probably never think about – the letter of medical necessity.
This single piece of paperwork can mean the difference between getting the care you need and facing thousands of dollars in out-of-pocket expenses. The following collection of expertly crafted letters will show you exactly how to present your case in the most compelling way possible, giving you the best chance of approval for your medical needs.
Sample Letters of Medical Necessity
Understanding how to structure and present your medical case can significantly impact your insurance approval rates. Each letter below demonstrates different approaches and scenarios you might encounter.
1. Letter for Durable Medical Equipment
[Insert recipient’s address]
Dear Insurance Review Team,
I am writing to request coverage for a hospital-grade electric bed for my patient, Mrs. Sarah Johnson (Policy #: 12345-ABC), who requires this equipment due to her severe chronic obstructive pulmonary disease (COPD) and congestive heart failure.
Mrs. Johnson’s condition has progressed to the point where she experiences significant respiratory distress when lying flat. Her current symptoms include severe shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. The adjustable positioning provided by an electric hospital bed is medically necessary to maintain proper airway alignment and reduce the work of breathing during rest periods.
Clinical documentation shows Mrs. Johnson’s forced expiratory volume (FEV1) has decreased to 35% of predicted normal values, placing her in the severe COPD category. Her ejection fraction has dropped to 25%, indicating advanced heart failure. The combination of these conditions makes standard sleeping positions dangerous and potentially life-threatening.
The electric bed will allow Mrs. Johnson to elevate her head and upper body to the optimal angle for breathing, reducing cardiac workload and preventing dangerous drops in oxygen saturation during sleep. This positioning is medically necessary to prevent emergency room visits and potential hospitalizations.
I have tried alternative treatments including multiple medications, oxygen therapy, and various positioning aids, but Mrs. Johnson continues to experience severe symptoms without the proper bed positioning that only an electric hospital bed can provide.
Thank you for your prompt consideration of this medically necessary request. Please contact my office if you require additional documentation.
Sincerely,
[Insert sender’s name and medical credentials]
2. Letter for Specialized Therapy Services
[Recipient’s complete address]
To Whom It May Concern:
This letter serves as a formal request for authorization of intensive physical therapy services for Mr. David Chen (Member ID: 987-65-4321), who suffered a traumatic brain injury following a motor vehicle accident on March 15, 2024.
Mr. Chen presents with significant motor impairments including left-sided hemiparesis, severe balance deficits, and coordination problems that substantially limit his ability to perform basic activities of daily living. His current functional status requires assistance for transfers, ambulation, and self-care tasks.
Neurological testing reveals damage to the right motor cortex and cerebellum, resulting in persistent weakness and ataxia. Without intensive rehabilitation, Mr. Chen faces permanent disability and complete dependence on caregivers. The requested therapy program includes three sessions per week of specialized neurological rehabilitation for twelve weeks.
The treatment plan incorporates gait training, balance retraining, functional mobility exercises, and adaptive equipment training. Research demonstrates that intensive therapy within the first six months post-injury provides the greatest opportunity for neuroplastic recovery and functional improvement.
Standard therapy approaches have shown limited progress due to the complexity of Mr. Chen’s injuries. The specialized neurological rehabilitation program offers evidence-based interventions specifically designed for traumatic brain injury recovery, including constraint-induced movement therapy and task-specific training protocols.
Early intervention is critical for Mr. Chen’s recovery potential. Delaying this specialized treatment will likely result in permanent functional limitations and increased long-term care costs.
I respectfully request your immediate approval for this medically necessary treatment program.
Best regards,
[Sender’s full name and professional title]
3. Letter for Prescription Medication Coverage
[Address of insurance provider]
Dear Medical Director,
I am requesting prior authorization for Humira (adalimumab) 40mg/0.8ml prefilled pen for my patient, Ms. Jennifer Williams (Policy Number: 555-HEALTH-123), who has been diagnosed with severe rheumatoid arthritis that has failed to respond to conventional therapy.
Ms. Williams has been under my care for eighteen months, during which time we have systematically tried multiple disease-modifying antirheumatic drugs (DMARDs) including methotrexate, sulfasalazine, and leflunomide. Each medication either produced intolerable side effects or failed to adequately control her disease progression.
Her current disease activity score (DAS28) remains elevated at 6.2 despite maximum tolerated doses of conventional therapy. Laboratory findings show persistently elevated inflammatory markers with ESR of 85 mm/hr and CRP of 12.5 mg/L. Joint imaging reveals progressive erosive changes in multiple joints.
Ms. Williams experiences daily pain rated 8/10, morning stiffness lasting over two hours, and significant functional impairment affecting her ability to work as a graphic designer. Her Health Assessment Questionnaire score of 2.1 indicates substantial disability.
Adalimumab represents the most appropriate next step in her treatment algorithm according to current rheumatology guidelines. Clinical trials demonstrate superior efficacy of TNF inhibitors like adalimumab in patients who have failed conventional DMARD therapy.
The cost of delayed treatment includes potential joint destruction, permanent disability, and lost productivity. Early aggressive treatment with biologics has been shown to prevent irreversible joint damage and maintain functional capacity.
I urge your expedited approval of this medically necessary medication to prevent further disease progression.
Sincerely,
[Doctor’s name and rheumatology credentials]
4. Letter for Diagnostic Testing
[Insurance company address details]
Dear Coverage Review Department,
This letter requests approval for magnetic resonance imaging (MRI) of the lumbar spine with and without contrast for Mr. Robert Martinez (Group #: CORP-2024-789), who presents with progressive neurological symptoms suggesting possible spinal cord compression.
Mr. Martinez has developed severe lower back pain radiating into both legs, accompanied by numbness, tingling, and weakness in his feet over the past six weeks. His symptoms have worsened significantly despite conservative treatment including physical therapy, anti-inflammatory medications, and activity modification.
Physical examination reveals diminished reflexes in both lower extremities, decreased sensation in the L4-L5 dermatomes, and weakness in dorsiflexion bilaterally. Straight leg raise test is positive at 30 degrees bilaterally, suggesting nerve root involvement.
Conservative treatment has been exhausted without improvement. Mr. Martinez now reports difficulty walking more than fifty feet and experiences significant pain that interferes with sleep and daily activities. His functional status has declined rapidly, raising concern for progressive neurological compromise.
Plain radiographs show degenerative changes but cannot adequately evaluate soft tissue structures, nerve roots, or potential disc herniation. MRI imaging is the gold standard for evaluating spinal pathology and is essential for determining the presence and extent of neural compression.
Without proper imaging, we cannot determine if Mr. Martinez requires surgical intervention to prevent permanent neurological damage. The clinical presentation suggests possible cauda equina involvement, which requires immediate evaluation and potential emergency treatment.
Time is critical in preventing irreversible neurological injury. I request expedited approval for this essential diagnostic study.
Respectfully,
[Physician name and specialization]
5. Letter for Home Health Services
[Recipient address information]
Subject: Medical Necessity for Home Health Services – Mrs. Dorothy Thompson
Dear Case Manager,
I am writing to document the medical necessity for comprehensive home health services for Mrs. Dorothy Thompson (Policy ID: HH-2024-456), an 82-year-old patient recently discharged following total hip replacement surgery complicated by postoperative infection.
Mrs. Thompson lives alone and has multiple comorbidities including diabetes mellitus, hypertension, and mild cognitive impairment. Her surgical recovery has been complicated by a deep tissue infection requiring intravenous antibiotic therapy for six weeks.
She requires skilled nursing visits three times per week for wound assessment, dressing changes, and intravenous medication administration. Her wound shows signs of delayed healing with continued drainage, requiring specialized wound care techniques and close monitoring for signs of osteomyelitis.
Physical therapy is necessary twice weekly to address significant deconditioning and mobility impairments. Mrs. Thompson currently requires a walker for ambulation and needs assistance with transfers. Without proper rehabilitation, she risks falls, fractures, and loss of independence.
Occupational therapy services are needed to address activities of daily living deficits and home safety concerns. Mrs. Thompson struggles with medication management due to her cognitive impairment and requires education on infection control measures.
Home health aide services are medically necessary for assistance with bathing, wound care, and medication reminders. Mrs. Thompson’s daughter lives three hours away and cannot provide daily assistance. Without these services, Mrs. Thompson faces high risk of complications, rehospitalization, and potential nursing home placement.
The interdisciplinary home health team approach is the most cost-effective way to manage Mrs. Thompson’s complex medical needs while allowing her to remain safely in her home environment.
Thank you for your consideration of this request.
Warm regards,
[Provider name and credentials]
6. Letter for Mental Health Treatment
[Insurance carrier address]
To the Mental Health Review Board:
I am requesting authorization for intensive outpatient mental health treatment for Ms. Amanda Foster (Member #: MH-789-2024), who presents with severe major depressive disorder with psychotic features following a recent suicide attempt.
Ms. Foster was hospitalized for five days after a serious suicide attempt involving medication overdose. She continues to experience severe depression with Hamilton Depression Rating Scale score of 28, indicating severe depression. She reports persistent suicidal ideation, auditory hallucinations, and severe functional impairment.
Her psychiatric history includes multiple failed medication trials and previous hospitalizations. Current symptoms include sleep disturbance, loss of appetite, psychomotor retardation, and inability to concentrate. She has lost her job due to attendance problems and is at risk of losing her housing.
The intensive outpatient program (IOP) provides structured treatment five days per week for six hours daily, including group therapy, individual therapy, medication management, and crisis intervention services. This level of care is necessary to prevent rehospitalization while providing intensive support for stabilization.
Ms. Foster meets all criteria for IOP level of care based on her recent suicide attempt, ongoing suicidal ideation, psychotic symptoms, and need for intensive monitoring while transitioning from inpatient care. Less intensive treatment options have proven inadequate given her severe symptom presentation.
Without this intensive treatment, Ms. Foster remains at high risk for another suicide attempt, extended hospitalization, or complete functional deterioration. The IOP program offers the best opportunity for stabilization and recovery while being more cost-effective than continued inpatient treatment.
Clinical research supports intensive outpatient treatment for patients with severe depression and psychotic features, showing improved outcomes and reduced rehospitalization rates compared to standard outpatient care.
I strongly recommend immediate approval for this medically necessary treatment program.
Sincerely,
[Psychiatrist name and professional credentials]
7. Letter for Surgical Procedure
[Complete recipient address]
Dear Medical Review Committee,
I am requesting preauthorization for laparoscopic gastric sleeve surgery for Mr. James Wilson (Policy #: SURG-2024-123), who meets all clinical criteria for bariatric surgery and has exhausted nonsurgical weight management options.
Mr. Wilson is a 45-year-old male with a BMI of 42.3 kg/m² and multiple obesity-related comorbidities including type 2 diabetes, hypertension, sleep apnea, and non-alcoholic fatty liver disease. His current weight of 285 pounds represents a significant health risk requiring surgical intervention.
He has participated in medically supervised weight loss programs for over two years without achieving sustained weight reduction. Documentation shows compliance with dietary counseling, exercise programs, and pharmacological interventions, all of which have failed to produce clinically significant weight loss.
Mr. Wilson’s diabetes is poorly controlled with HbA1c of 9.2% despite maximum medical therapy. His blood pressure requires three medications for control, and he uses CPAP therapy for severe obstructive sleep apnea. Liver biopsy confirms advanced hepatic steatosis.
Bariatric surgery represents the only evidence-based treatment option for achieving substantial, sustained weight loss in patients with severe obesity. Clinical studies demonstrate superior outcomes for surgical treatment compared to nonsurgical approaches in patients meeting Mr. Wilson’s criteria.
The laparoscopic sleeve gastrectomy is the most appropriate surgical option based on Mr. Wilson’s anatomy, comorbidities, and treatment goals. This procedure offers excellent weight loss outcomes with acceptable risk profile and has been shown to improve or resolve diabetes in over 80% of patients.
Continued conservative management will likely result in progressive deterioration of Mr. Wilson’s health status, increased medical costs, and eventual development of life-threatening complications.
I request your prompt approval for this medically necessary surgical intervention.
Best professional regards,
[Surgeon’s name and board certifications]
8. Letter for Extended Care Facility
[Address of insurance reviewer]
Dear Utilization Review Department,
This letter documents the medical necessity for continued skilled nursing facility care for Mr. George Patterson (Policy #: SNF-2024-890), who requires ongoing rehabilitation and medical management following stroke with significant residual deficits.
Mr. Patterson suffered a left middle cerebral artery stroke six weeks ago, resulting in right-sided hemiplegia, dysphagia, and expressive aphasia. He has made some progress during his initial rehabilitation but continues to require intensive skilled nursing care and therapy services.
His current functional status includes dependence for all transfers, inability to ambulate independently, and need for assistance with all activities of daily living. Swallowing studies show continued aspiration risk requiring modified diet consistency and close monitoring during meals.
Speech therapy is ongoing to address severe aphasia limiting his communication abilities. Physical therapy focuses on mobility training and prevention of complications including contractures and deep vein thrombosis. Occupational therapy addresses self-care skills and cognitive retraining.
Mr. Patterson requires skilled nursing care for medication management, wound care for a stage 2 pressure ulcer, and monitoring for stroke complications. His blood pressure remains labile, requiring frequent medication adjustments and monitoring.
Discharge planning is complicated by his wife’s inability to provide necessary care due to her own health problems, including advanced arthritis and recent cardiac surgery. Home modifications and caregiver arrangements are being pursued but require additional time to implement safely.
Premature discharge would place Mr. Patterson at high risk for complications, falls, medication errors, and rehospitalization. The skilled nursing facility provides the appropriate level of care for his current medical and functional needs.
I recommend continued authorization for skilled nursing facility care for an additional thirty days while rehabilitation continues and safe discharge arrangements are finalized.
Respectfully submitted,
[Medical director name and qualifications]
9. Letter for Specialty Consultation
[Reviewer’s address block]
Dear Prior Authorization Team,
I am requesting approval for neurosurgical consultation for Mrs. Helen Rodriguez (ID #: NEURO-2024-456), who presents with complex spinal pathology requiring subspecialty evaluation for potential surgical intervention.
Mrs. Rodriguez has developed progressive myelopathy over the past four months, with symptoms including weakness in both arms, difficulty with fine motor tasks, and gait instability. Her condition has deteriorated significantly despite conservative treatment.
MRI imaging reveals multilevel cervical stenosis with cord compression at C4-C5 and C5-C6 levels. There is evidence of T2 hyperintensity within the spinal cord, suggesting myelomalacia. Her cervical myelopathy is causing progressive neurological deterioration.
Physical examination shows upper motor neuron signs including hyperreflexia, positive Hoffmann’s sign bilaterally, and sustained clonus. Electromyography confirms cervical radiculopathy with evidence of chronic denervation in multiple myotomes.
Mrs. Rodriguez’s functional capacity has declined rapidly. She has difficulty buttoning clothes, writing, and walking without assistance. Her Nurick grade has progressed from 2 to 4 over the past two months, indicating significant disability from cervical myelopathy.
Neurosurgical evaluation is urgently needed to determine if surgical decompression is necessary to prevent permanent neurological injury. Cervical myelopathy with progressive symptoms requires subspecialty assessment for potential surgical intervention.
Conservative treatment has been ineffective, and further delay in evaluation may result in irreversible spinal cord damage. The window for surgical intervention may be closing as myelopathy progresses.
I request expedited authorization for neurosurgical consultation to evaluate Mrs. Rodriguez’s candidacy for cervical decompression surgery.
Thank you for your urgent consideration.
Sincerely,
[Referring physician name and specialty]
10. Letter for Prosthetic Device
[Insurance processor address]
Subject: Prior Authorization Request – Myoelectric Prosthetic Arm
Dear Medical Review Team,
I am writing to request coverage for a myoelectric prosthetic arm for Mr. Timothy Brooks (Policy #: PROS-2024-321), who recently underwent above-elbow amputation following traumatic injury in an industrial accident.
Mr. Brooks lost his dominant right arm in a workplace accident involving heavy machinery. The amputation was performed at the mid-humeral level, leaving adequate residual limb length for prosthetic fitting. He is a 34-year-old construction supervisor who is highly motivated to return to productive employment.
Standard body-powered prosthetics are inadequate for Mr. Brooks’ vocational and functional needs. His job requires precise manipulation of tools, lifting capacity, and bilateral coordination tasks that cannot be accomplished with conventional prosthetic devices.
The myoelectric prosthetic system uses EMG signals from residual muscles to control multiple functions including elbow flexion, wrist rotation, and hand grip. This technology will allow Mr. Brooks to perform complex bilateral tasks necessary for his occupation and daily living activities.
Prosthetic evaluation confirms adequate residual limb condition for myoelectric fitting. EMG testing shows strong, consistent signals from target muscle groups. Mr. Brooks has completed prerequisite physical therapy and demonstrates excellent potential for successful prosthetic use.
Vocational rehabilitation assessment indicates that with appropriate prosthetic fitting, Mr. Brooks can return to supervisory duties in construction management. His employer has confirmed willingness to accommodate his return to work with proper prosthetic equipment.
The myoelectric system represents the most cost-effective solution for achieving functional independence and return to productive employment. Alternative approaches including job retraining or permanent disability would result in significantly higher long-term costs.
I strongly recommend approval for this prosthetic device to maximize Mr. Brooks’ rehabilitation potential and functional outcomes.
Professional regards,
[Prosthetist name and certification credentials]
Conclusion
Getting your medical treatment approved doesn’t have to feel like fighting an uphill battle. The key lies in presenting your case with precision, supporting documentation, and clear medical justification that insurance reviewers can easily understand and approve.
Each letter template above demonstrates specific strategies for different medical scenarios, but they all share common elements that make them effective. Your medical provider needs to clearly establish the diagnosis, explain why the treatment is necessary, document failed alternatives, and present the consequences of denial.
Remember that insurance companies are businesses making financial decisions, but they’re also bound by medical necessity standards and regulatory requirements. When your case is presented professionally with strong clinical justification, approval rates increase significantly.
The most important factor in any medical necessity letter is timing. Don’t wait until you’re facing an emergency situation to start the authorization process. Work with your healthcare team early to build a strong case, gather supporting documentation, and submit requests with adequate time for review and potential appeals.
Your health is worth advocating for, and these letter templates give you the roadmap to present your case effectively. Use them as starting points, customize them for your specific situation, and work closely with your medical team to ensure all necessary supporting documentation is included.