SAMPLE LETTER OF MEDICAL NECESSITY
Physician’s Letterhead
Date
City, State, ZIP Code
RE: Coverage for Health and Wellness Coaching
Patient: Patient Name
Date of Birth: Date
Diagnosis: Diagnosis, ICD-10-CM
Dear HSA/FSA Plan:
I am writing on behalf of my patient, Patient Name, to document the medical necessity to treat their Diagnosis with Coach name, a National Board Certified Health and Wellness Coach at (Coach Business LLC Name / NPI: xxxxxxxxx / EIN: xx-xxxxxxx / Health and Wellness Coaching Taxonomy code: 71400000X).
This letter serves to document my patient’s medical history and diagnosis and to summarize my treatment rationale. Please refer to the List any Enclosures enclosed with this letter.
Summary of Patient’s Medical History and Diagnosis
Patient Name is Age years old and was initially diagnosed with Diagnosis ICD-10-CM on Date. Patient Name has been in my care since Date.
Provide a discussion of the patient’s clinical history, current symptoms and condition, any potential contraindications, and any relevant laboratory test results, highlighting the factors leading you to recommend use of the service
Rationale for Treatment
Include your clinical rationale and reasons for prescribing the service
In summary, Service Name is medically necessary and reasonable to treat Patient Name’s Diagnosis, and I ask you to please consider coverage of Service Name on Patient Name’s behalf. Please refer to the enclosed supporting documents for further details, and do not hesitate to call me at Phone Number if you have any questions or if you require additional information.
Thank you for your attention to this matter.
Sincerely,
Provider Signature
Prescribing Physician Name and Credentials
NPI Number
Enclosures: List any Enclosures