As we approach the new school year and summer vacations are winding down, many of our children will complete annual visits to the physician, dentist, or specialist. In many cases, it is essential to obtain approval for medical services to ensure insurance coverage associated with the cost of their care.

For more than ten years, I have had to seek approval for numerous products and services to support Catherine’s well-being. The requests covered therapy, sleep studies, neurological evaluations, home health care, durable medical equipment, prescription drugs and more. It is safe to assume that most medical products and services require an endorsement from insurance providers. This approval is often granted based on a Letter of Medical Necessity (LMN). As you seek authorization of services for your next visit to your medical provider, here are a few vital questions to consider:

What is Medical Necessity?

According to the Social Security Act, medical necessity is a legal term which “denotes healthcare products or services provided to a patient that is necessary for the diagnosis or treatment of an illness or injury.” This is a legal document required by the IRS to verify certain expenses.

Who provides a LMN?

A Letter of Medical Necessity (LMN) is a document written or endorsed by a physician to verify that a product or service is required for a patient. A physician may write a prescription explaining patient history, diagnosis, basis for treatment, and duration. Make sure it is signed by a physician and appears on letterhead for the physician’s practice. See link below for a suggested sample LMN letter. https://nuesynergy.com/sites/default/files/sample_letter_medical_nec.pdf

When to obtain a LMN?

It is important to seek and obtain approval prior to receiving medical products and services. Approval can take anywhere from a few days to several weeks. If the need is unclear, an insurance provider may ask for additional documentation. Many physicians are accustomed to the process. It is important to understand the full coverage granted so you are not surprised by an unexpected expense.

Does a LMN guarantee insurance coverage?

A LMN does not guarantee insurance coverage for a product or service. A procedure may be medically necessary, but your insurance carrier may not offer coverage for this treatment. There is also the case where coverage is granted with limitations. If a patient requires visits to physical therapist for rehabilitation, a provider may only approve a restricted number of visits. Once the visits are exhausted, additional treatment could require out of pocket payment.

What happens if insurance coverage is denied?

If coverage is denied, insurance carriers provide an appeal process. You will receive written notification of denial and detailed insight on the process and timeframe for your appeal. It is important to respond in a timely manner as outlined in the appeal form. I’ve been through an appeal process a number of times and have fortunately succeeded in a few and lost others. In the end, I realized the importance of following through for services that are important to Catherine’s care.

The LMN is the cornerstone for access to the highest level of care for your loved ones. I hope you find these tips useful as you plan for your next visit to your healthcare provider.