Letter of Medical Necessity (LMN) Samples
LMN SAMPLE #1
December 10,1998
To Whom It May Concern:
XXXX has poor oral motor coordination due to her XXX and XXX. These factors prevent her from producing verbal communication. It has been deemed as a medical necessity that XXXX continue to use an Augmentative Communication Device (speech prosthesis). XXXX is mentally alert and recognizes her needs. Medically she needs to be able to communicate when she is not feeling well, and specifically what her symptoms are to staff and her physician. In addition the speech prosthesis will help her communication in situations of emergency. An upgrade in her communication system would increase her ability and opportunity to communicate. It would also increase her control over her environment decreasing her dependency upon staff. Her current communication system has proven to be inefficient and inadequate in for environmental and computer access, access to messages on her screen, and ability to efficiently generate new messages. Her use of an upgraded Augmentative Communication System would increase her ability in the above listed areas and thus improve her quality to life.
Therefore, I recommend a [device name here] and warranty.
The [device name here] with its accessories XXXX would promote independence, self care, and self respect. XXXX increase in independence will have a positive impact upon her mental health. The [device name] is built to withstand use and is the most cost effective medical device deemed appropriate for her. Also the warranty is excellent covering everything except theft and loss. This device will replace for XXXX an abnormally enervated body part (oral musculature) and insufficient body function (oral speech). If you have any questions please don't hesitate to contact me. Thank You.
Sincerely,
XXXX
LMN SAMPLE #2
Patient: XXXX
Diagnosis: XXXX
Concerning: Letter of Medical Necessity
To whom it may concern:
This letter is to emphasize the necessity of an augmentative communication device as a rehabilitative device and a life long communication requirement for XXXX.
XXXX has the cognitive ability to produce complex communication, however, her physical limitations severely impair this ability. She needs to communicate critical information concerning medical, emergency, and daily care information to physicians, therapists, and staff in each of her daily environments of home, work and community outings. She also needs to effectively communicate complex issues and emotions in her life to assist in her decision making process.
She currently is utilizing a loaner [device name here]. Her original [previous device name here] is in need of significant repair. She has been utilizing features on the [device name] that are unavailable on her original [previous device name] such as word prediction and environmental control. The [device name] is the current model of the [device name] in production. The [device name] would increase XXXX efficiency in communicating by decreasing key strokes per message by allowing more messages to a page. This is accomplished through pop-ups that enlarge the portion of the grid she touched allowing her to then further select a specific message. It would also increase her writing efficiency through word prediction. The [device name] has a color active matrix screen for greater visual clarity. Finally the [device name] would allow her to have independent access and control of items in her environment such as a computer, her TV, VCR, and lights.
In summary, XXXX would benefit in many ways by replacing her Original [previous device name] with a [device name]. I strongly urge that funding of such a device be covered for the above noted reasons. If you have any questions please feel free to contact me.
Sincerely,
XXX
LMN SAMPLE #3
August 19, 1996
To Whom It May Concern:
XXXX has poor oral motor coordination due to her neurological development resulting in few poorly articulated words for communication. It has been deemed as a medical necessity that XXXX receive and use an Augmentative Communication Device (speech prosthesis). XXXX is mentally alert and recognizes her needs. She experiences extreme frustration resulting in Self Injurious Behavior when she is unable to communicate her message. Medically she needs to be able to communicate when she is not feeling well, and specifically what is wrong with her to staff and her physician. In addition the speech prosthesis will aide her communication in situations of emergency. Her current communication system has proven to be inadequate to convey her needs, therefore her medical care is compromised. Her use of a speech prosthesis would also provide XXXX with the ability to speak privately with her medical staff preserving confidentiality regarding her medical concerns.
Therefore, I recommend a [device name here], antiglare shield, wall transformer, and an extended warranty.
The [device name] with accessories appropriate for XXXX would decrease her self injurious behaviors and promote independence, self care and self respect. It would also make a transition to a community setting much smoother ensuring XXXX ability to communicate her needs to unfamiliar people. The [device name] is built to withstand use and is the most cost effective medical device deemed appropriate for her. Also the warranty is excellent covering everything except theft and loss. This device will replace for XXXX an abnormally enervated body part (oral musculature) and insufficient body function (oral speech), restoring her facility for functional speech.
Sincerely,
XXXX
LMN SAMPLE #4
Patient: XXXX
Diagnosis: XXXX
Concerning: Letter of Medical Necessity
To whom it may concern:
This letter is to emphasize the necessity of an augmentative communication device as a rehabilitative device and a life long communication requirement for XXXX. Due to XXXX neurological development she is unable to produce verbal speech. She is, however, capable of utilizing verbal speech output when given an avenue of access.
The inability to produce verbal speech is a severe disability, as XXXX has the cognitive ability to communicate. She needs to communicate critical information concerning medical, emergency, and daily care information to physicians, therapists, and staff in each of her daily environments of home, work and community outings. An augmentative communication device, specifically the [device name here], would remove much of the obstacle of her communication difficulties and decrease her frustration level and consequently the frequency of her self injurious behavior.
To specifically address the benefits of her communication device:
- The [device name] is necessary for XXXX to effectively communicate her physical condition, symptoms, need to be repositioned, etc. to her medical personnel, therapists and her direct care staff.
- This device would improve self support and reduce her dependency.
- This device is necessary to allow XXXX to function at her optimal level.
In summary, the use of augmentative communication is an accepted avenue in modern medical management and rehabilitative services. I strongly urge that funding of such a device be covered for the above noted reasons. If you have any questions please feel free to contact me.
Sincerely,
LMN SAMPLE #5
Re:
DOB:
To Whom It May Concern:
I had the pleasure of working with xxxx during a recent Augmentative Communication Evaluation at the [AT Provider agency here]. This evaluation was conducted to examine some of xxxx’s communication impairments related to xxxxx.
One recommendation was for a speech prosthesis to help xxxx more effectively express xxxx in a way that is consistent with her receptive language skills and her demonstrated expressive language potential. The recommended device is a [device name here], speech output communication system. This is available from [manufacturer name here]
This speech prosthesis will help XXXXXX accurately express XXX:
- physical and health status (such as specific information about pain, discomfort and distress);
- personal needs (including nutritional needs, hygiene needs, etc.);
- requests for assistance (especially in emergency situations when XXX is with adults and caregivers who are not familiar with XXX idiosyncratic speech);
- personal wants.
This device is durable medical equipment. This and similar devices have been classified as such by insurance carriers in many states, such as Blue Cross-Blue Shield, Aetna US Healthcare, and Medicaid. It is a Speech Generating Device in the Centers for Medicare & Medicaid Services classification system. The Product Code in CMS’s system is [product code here]. In XXXX’s case, it is medical equipment as:
- XXX need for it is directly related to XXX medical diagnosis;
- it replaces an abnormally enervated body part (oral musculature) and abnormal and insufficient body function (oral speech);
- XXX need for it is projected to be long-term;
- it is appropriate to XXX current and projected language, visual and motor skills (see Augmentative Communication Evaluation).
Finally, medical equipment like this can be used throughout a child’s life, including for multiple purposes. While this equipment directly addresses xxx medical condition and needs, it also will support xxx development of progressively more independent and appropriate skills. This, however, is also one goal of medical/health care treatment for children of xxxxxx age. In fact, our “cost-benefit” analysis of equipment is more positive when a child can benefit in more than one way from his time and learning investment in the device and from a funding agency’s financial investment. It is also why we ask vendors who do training in the operation, programming, and maintenance of such equipment to meet with all of a child’s team members at once (e.g., family members, home health providers, therapists, teachers, etc.).
The fact that medical equipment can be used in different environments and for corresponding functional purposes does not deny its medical necessity. If it did, then wheelchairs which help an individual ride on a school bus to school and portable ventilators which enable a person to go to the grocery store would not be considered “durable medical equipment”.
I hope this information is helpful to you. Thank you for your assistance in making this equipment available to XXXXXX—and contributing to XXX improved health care through increased independence. Please call me at (xxx) xxx-xxxx if I can provide any additional information.
Sincerely,
XXXX