Letter of Medical Necessity

Aka: Letter of Medical Necessity

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II. Protocol: Step 1 - General Information

  1. List demographic information
  2. List diagnoses with ICD9 Codes

III. Protocol: Step 2 - Functional limitations

  1. Balance Disorder
  2. Developmental Delay
  3. Hypotonia
  4. Joint deformity or instability
  5. Level of limb loss (Right, Left or Bilateral)
  6. Pain
  7. Respiratory deficiency
  8. Skin disorder
  9. Spinal deformity
  10. Weakness
  11. Paralysis
    1. Hemiparesis (Right, Left or Bilateral)
    2. Hemiplegia (Right, Left or Bilateral)
    3. Paraparesis
    4. Quadriparesis
    5. Diplegia
      1. Paraplegia
      2. Quadriplegia
      3. Spasticity
      4. Athetosis

IV. Protocol: Step 3 - Patient status

  1. Report format
    1. "Due to patient's function limit, unable to..."
  2. Performance abilities
    1. ADL or IADL
    2. Functional mobility
    3. Work activities

V. Protocol: Step 4 -Use of Equipment

  1. Report format
    1. "Use of this equipment will..."
  2. Perform
    1. Function independently
      1. With device or equipment
      2. With modified environment
    2. Perform independent Wheelchair mobility
      1. Home
      2. Community
    3. Return home
    4. Required as lifetime medical need

VI. Protocol: Step 5 - Equipment Description (examples)

  1. Wheelchair
    1. Electric, Manual, or Manual backup
    2. One-arm drive, power scooter, or quad system
    3. Replacement or repair
  2. Wheelchair frame
    1. Lightweight, Nonstandard, or Reclining
  3. Wheelchair accessories
    1. Armrests or hand rims
    2. Leg or foot rests
    3. Seat Belts
    4. Tires or Casters, Axel, Locks, and Rear wheels
  4. Other
    1. Bathing or toileting aids
    2. Anti-embolus stockings
    3. Back support
    4. Hospital bed
    5. Transfer lift
    6. Communication aids
    7. Vision aids (including High tech)
    8. Long white cane, walker, cane, or prone stander
    9. Hearing Aids and other Hearing assistance devices

VII. Protocol: Step 6 - Rationale (examples)

  1. Safety
  2. Cost effective in prevention of secondary complications
  3. Prevention of additional functional limits
  4. Mobility restrictions preventing independent activity
  5. Access to home areas, bathroom, and kitchen
  6. Access to workplace or school
  7. Past experience, interventions, results
  8. Duration of expected use
  9. Goals or benefits to patient

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