Letters of Medical Justification

The path to insurance coverage is a challenging one, but persistence and preparation are your best tools to navigate this path. Many insurance providers in the United States are becoming more aware of adaptive mobility devices and alternative seating, but at the same time, the standards to clear for approval are evolving. Parents must be armed with an impeccable medical package to submit if they hope for approval.

Parents should also contact their insurance provider prior to starting the process to find out if their plan has out-of-network coverage. Please keep in mind that typically insurance does not cover the cost of adaptive bikes. However, there are situations where the bike can be justified and approved. The more premium of a plan you have, the better chance you have to receive coverage for an adaptive bike.

All Insurance Submissions Begin with a Letter of Medical Justification.

The Letter of Medical Justification is a very important document. It not only sets up the possibility of approval, it can lay the foundation for an appeal should the family wish to file an appeal following a denial. A comprehensive and well-written letter of medical justification will become very important in the event of a hearing or appeal.

What are the must haves for this medical package?

1: What is the Medical Justification Language?

Insurance providers want to know about the child’s diagnosis and how the device will address or benefit this specific diagnosis. The letter must include a written explanation of the diagnosis, along with the applicable ICD code. It is critical to address BOTH those items in the letter.

A description of the device, including all the accessories and features that make it adaptive and not off-the-shelf is the next language to include. A well-drafted letter of medical justification should state WHY an off-the-shelf purchase cannot be adapted successfully to meet the patient’s needs, or what this particular piece of equipment offers that cannot be found elsewhere.

Remember that the insurance providers typically are looking for MEDICAL NECESSITY.  The letter must define the following points:

How does the piece of equipment do the following?

  • Meet the patient’s medical needs?
  • Reduce the person’s physical or mental disability?
  • Restore the patient’s best possible functional level or improve their capacity for normal activity?

The physician or therapist must adequately and medically justify why the equipment is necessary for the treatment, habilitation or rehabilitation of the beneficiary. It should focus heavily on medical information and steer clear of any social, psychosocial and leisure benefits.

Finally, the letter should discuss why nothing else will meet the individual’s medical needs except this adaptive tricycle or alternative seating.

Don’t forget the ICD code!

2: Who is the letter from?

All insurance providers ask, first and foremost, for a letter from a pediatrician (or neurologist if applicable).

A letter from a PT, an OT or a DPT can be an excellent secondary document, but a letter from a therapist alone will not meet the standards for medical justification. Any letter from a therapist must be accompanied by a letter from a physician, pediatrician, neurologist, or your child’s other primary medical caregiver.

Alternatively, your primary caregiver can draft a short concurrence statement at the end of the letter from the therapist, providing their name, title, clinic and facility information, their NPI number and their signature. Lastly, they can state, in a short paragraph, that they, as the primary caregiver, support the conclusions of the therapist’s letter.

This should only be used if getting a letter from your pediatrician or neurologist isn’t possible -for whatever reason it does not have the same impact.

****** Freedom Concepts can supply you with examples of medical justification letters that have been used successfully in previous insurance claims. Give us a call, toll-free, at 1.800.661.9915

3: What else is in the medical package?

An actual prescription for an “adapted mobility device” must be included. This prescription must be legible, clear and contain the following information:

  • Signature of the physician who wrote the letter
  • State the ICD code(s) on the prescription
  •  Include the physician’s NPI number (National Provider Identification) if they have one

Please do not hesitate to give our funding specialists a call at 1-800-661-9915 for further information.

The following insurance companies have recognized the therapeutic benefits of our adaptive mobility devices and alternative seating:

  • Blue Cross/Blue Shield
  • Special Programs for Active Military Members and Their Children

It is also very important to point out the long-term benefits. These benefits include:

  • Bone Growth
  • Strengthening of Anti-Gravity Muscles
  • Development of Hand/Eye Coordination
  • Respiratory Activity
  • Development of Head and Trunk Control