Jul 23, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Maybe you received a denial, you’ve already appealed it once, and now you want to appeal again, but this time, you will include additional information to make your case of why the claim should be paid. If you haven’t written an appeal in the form of a medical necessity letter, chances are you’re wondering what should be included.
Rarely do you need a letter of medical necessity if you’re submitting for a pre-authorization. Most payers have templates for what they want to see for medical necessity, and by using the informational template, being thorough, and following all payer guidelines, you should obtain the pre-auth. But when it comes to appeals, you have a little more work to do. Keep reading for a helpful list of what to include as you craft a letter of medical necessity for appeals at your retina clinic.
A medical necessity letter can be written by the physician or an experienced administrator, biller, or scribe—but the physician must sign it. Depending on the reason for the denial, the purpose may be to:
Does the chart support medical necessity? Learn how to improve medical documentation at your retina clinic.
A medical necessity letter is somewhat formal, so it should look like a business letter. Today, most practices correspond via email or have templated letters in the EHR or PM systems, so no one has to think about formatting a letter. While listing everything may seem overkill, we will touch on it anyway. The medical necessity letter should include the following:
Header:
Body of the letter:
Attachments: (see next section)
Physician signature: typed name of the physician, credentials, and contact information; the physician should sign above the typed name.
While the medical necessity letter presents your case, the attachments do most of the heavy lifting. Here is where you include documents supporting your argument, such as articles by other experts in the field supporting treatment, the payer criteria you met when you used an item or service, or the chart documentation supporting the medical necessity. It’s a good idea to reference your relevant attachments in the letter of medical necessity to make your rationale as straightforward as possible. Also, consider marking your attachments with highlighting, red marks, boxes, and arrows to demonstrate your point.
Relevant attachments include:
Once your medical necessity letter is written, printed, signed by the physician, and packaged with supporting attachments, it’s ready to send to your payer contact. Nice work!
The letter of medical necessity can be a bit of work, but receiving proper reimbursement for the services or items used by your retina clinic is worth it. In the appeals process, a well-crafted medical necessity letter can go far to support your claim. Be sure to include all relevant information that will bolster your argument and supporting attachments.
Need assistance with the appeals process, questioning the validity of your claims, or experiencing a pattern of denials at your retina clinic? Medical billing consultant Elizabeth Cifers specializes in retina billing and has decades of experience in medical administration. She can help you verify proper claims, correct errors, and make winning arguments for legitimate appeals. Book a free consultation call with Elizabeth here.
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