Many payors require that a prescribing physician or health care practitioner document a patient’s medical necessity for insurance coverage for a medical device for treatment.

Your physician or health care provider (also known as the prescriber) is responsible for the content and submission of this letter and should customize all bracketed information in blue with the appropriate payor, office, and patient information.

• A prescribing physician / health care practitioner should be aware that medical records must be included and be consistent with the information outlined in the Letter of Medical Necessity.
• Health plan requirements may vary, so the prescriber should refer to the prior authorization or coverage information specific to their patient’s health plan before completing a Letter of Medical Necessity.
• Use of this letter does not guarantee coverage for the product.
• The prescriber should refer to the Important Safety Information in the full Information for Use when determining whether the product is medically appropriate for a patient.

The following is intended as a sample Letter of Medical Necessity that outlines common information a payor may request.

You can share this sample Letter of Medical Necessity with your physician or health care practitioner as an example.

Download the Letter of Medical Necessity Example for Touchless Kit template