Writing Letters of Medical Necessity that Merits Insurance Approval

By Robin Hocevar

Even those who chose science as a career just to avoid another dreaded composition class need to choose their words carefully when requesting insurance funding for durable medical equipment.

Though the reimbursement climate varies from state to state, year to year, and by provider, the staff at SleepSafe® Beds have noticed some consistencies in the letters that are approved. To make the process less cumbersome, they’ve compiled examples of successful letters of medical necessity and are providing them as a free template on www.sleepsafebed.com.

Edward Hettig, marketing director for SleepSafe® Beds, said their staff has fielded questions from parents, doctors and therapists for years on what to include in the letter of medical necessity, which is usually required during the process of getting a SleepSafe Bed funded by insurance. While he admits it’s an imperfect science and the approval process may come down to a single whim, there are some golden rules. Clarity and persistence are key, he said, and the emphasis must remain on a direct correlation with the patient’s medical condition.

“The nature of the letter should pinpoint the medical needs of the child,” Hettig stated. “For instance, if a child has random seizures, note that padding should be installed in the bed as a safety feature to help prevent injury.”

Customer Service representative Donna Davis has noticed positive results when the need for an articulated foundation, with the ability to adjust head and knee elevation, is directly correlated with the child’s respiratory or reflux issues, for instance.

As a template, SleepSafe® representatives said the letters yielding the best outcomes include descriptions of how the current bed or crib fails to protect the child, acknowledgement of the psychological advantage for the child being able to see out the bed, bed model recommendations with specific requirements and the statement that specific requirements need to be met with a certain model.

Caregiver Benefit Trap

Though one of the features of SleepSafe® Beds may ease the burden for caregivers, mentioning that may be detrimental for reimbursement, according to Hettig.

“Some insurance providers may issue a denial if they notice a request for a Hi-Lo foundation that allows mattress height adjustment.  They may see it as a benefit for the caregiver, not the child,” he cautioned.

Davis has seen situations where insurance representatives have noted that if a child can’t work the Hi-Lo remote it is concluded that the bed must be for the parents’ convenience.

Bureaucratic Speak

Typically, letters of medical necessity are written by the child’s physical or occupational therapist, but they also can be crafted by doctors or even parents. It’s also somewhat common for the parent to draft the letter and then present to the doctor or therapist for a signature.

As the Medicaid or insurance company evaluator isn’t always a credentialed medical doctor, it’s important to include pertinent medical details without delving too deeply into complex jargon. The medical records will be attached to the letter of medical necessity (LMN) and will reveal further detail.

Although a picture is said to be worth 1,000 words, opinions are mixed on including a photo.

“We commonly hear that patients get tangled up in traditional hospital bed rails,” explained Davis. “Some people have included pictures of their child caught in the safety rail and explained this is why they’re investigating a safety bed. It has backfired on them because their insurance company thought it was inappropriate to take the time to photograph a trapped child.”

“Some insurance companies have criteria in place before considering funding a safety bed, including heart-wrenching ideas like having the child sleep with a helmet on a mattress on the floor,” Hettig noted. “Beds may then be approved when all of their criteria are met.”

Prepare to Appeal

Even the most well thought out letters are often denied depending on the state or even an unknown factor.

“It really depends on the state and the insurance provider,” remarked Hettig. “We’ve had customers who were denied six times. The persistent caregivers who file an appeal right away have a better chance of getting the bed covered.”

Anecdotally, Davis believes the recent Medicaid expansion in many states has led to more approvals. “We found working with Medicaid claims a few years ago very challenging, but we’ve had more calls from Medicaid and insurance clinicians interested in approving beds. They want to learn and educate themselves about the functionality and need for a SleepSafe® Bed, which is very encouraging.

Persistence and Patience

The process of getting your bed funded through insurance can sometimes be frustrating and time consuming, but be persistent and patient and don’t take no for an answer. It will be worth it when your loved one gets their new bed.


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