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Michigan Disability Rights Coalition is a disability justice movement working to transform communities.

If you are applying for funding, you will need to document your need for the AT you have chosen.  Each funding source will have their own forms and procedures so be sure to check on what documentation is required. If you have had a professional assessment, the information needed to document the need will be provided in the report. The sample “Letter of Medical Necessity” lists the elements to include in your documentation of your need for AT. 

Letter of Medical Necessity: What it is and what it should contain

A skillfully drafted letter of medical necessity is an essential part of a request for funding assistive technology. A letter of medical necessity, whether being submitted for Medicaid, a private insurance company or other funding source, should contain the information needed to convince the reader that the requested assistive technology is necessary to meet the medical needs of the person for whom the assistive technology is being requested.

A medical professional familiar with the requesting party’s medical condition should write the letter of medical necessity. The professional should briefly describe his/her credentials and relationship to the requesting party. This professional may be a physician, a nurse, a physical therapist, an occupational therapist or other medical professional. However, note that most funding sources require a physician's prescription as part of the funding request. Therefore, letters of medical necessity not written by a physician should be endorsed by a physician or accompanied by a physician's prescription.

A medical professional familiar with the requesting party’s medical condition should write the letter of medical necessity. The professional should briefly describe his/her credentials and relationship to the requesting party. This professional may be a physician, a nurse, a physical therapist, an occupational therapist or other medical professional. However, note that most funding sources require a physician's prescription as part of the funding request. Therefore, letters of medical necessity not written by a physician should be endorsed by a physician or accompanied by a physician's prescription.

Elements of the Letter

  1.    Disability Description: The letter should contain, usually at the beginning, a thorough description of your disability. This description should include an explanation of how the disability affects you. For example, explain the effects of the disability on the use and function of your legs. The disabling condition(s) and/or functional limitation(s), which necessitate the request for the assistive technology, should be highlighted.
  2.   Assistive Technology Description: The assistive technology being requested should be described in some detail. A more thorough description is required when the requested technology is new, unique, customized or not frequently requested.
  3.   Assistive Technology Relationship to Medical Needs: The letter should explain how the requested assistive technology addresses your medical needs or functional limitations. Generally in this context, a medical need is not a need to receive medical treatment. Rather, it is a need to compensate for a function that is limited as a result of a disability. For example, you have a medical need for a wheelchair to compensate for lost function in the lower extremities and to have a functional means of mobility.
  4.   Inability of Alternatives to Meet Medical Needs: Where there are alternatives, especially less expensive alternatives available to meet your medical needs, the letter should explain why these alternatives are not appropriate for you. Also, the specific features that make the requested technology the necessary and appropriate alternative should be identified.
  5.   Ability to Use Technology: The letter should detail your ability to use the requested assistive technology. This is especially important when the technology is motorized, electronic or particularly sophisticated. For example, when a power wheelchair is being requested, your ability to safely operate a power wheelchair should be noted. Summarize trial if one occurred.
  6.   Requested Assistive Technology as Community Standard: The letter should justify and explain your need for the assistive technology. This justification should be in terms of the community standard of practice by the medical professional's peer group. The medical professional should explain that it is the standard practice or current practice in their profession to provide the requested assistive technology to persons with your disability.

Sample Letter of Medical Necessity

The letter that follows is a sample Letter of Medical Necessity. The numbers in parenthesis are linked to the corresponding element in the above list.

RE: Ms. Jane Doe Clinic #: 4-124-109

DOB: 5/21/64

TO WHOM IT MAY CONCERN:

(1)Ms. Jane Doe is a 30-year-old woman with C5-6 quadriplegia related to a motor vehicle accident in 1985. Despite her significant disabilities, she had been able to achieve independent living with the assistance of a personal care attendant. However, she continues to have difficulties with environmental controls within her home due to her impaired upper extremity function.

(1) Due to Ms. Doe's high level of injury, she is unable to use her upper extremities to control her environment. She is in need of being provided with appropriate technology for permanent use. I recommend that a voice recognition system from Advanced Speech Interface Systems, Inc., be purchased and installed in Ms. Doe's present residence. (2) This company has demonstrated their equipment to us and will be able to provide ongoing service of their product.

(6) This system is medically necessary and is accepted among the medical community because it provides persons with C5-6 quadriplegia (like Ms. Doe) independent living to generate self-care and self-esteem as mandated under federal law. (6) In order to maximize Ms. Doe's functional independence, an environmental control system is medically necessary. (3) She would benefit from a (2) voice-controlled system that allows her the ability to control many functions within her home such as opening doors to exit her residence in emergency situations such as a fire, (4) since she is currently unable to do this without the assistance of a personal care attendant. (2) This system will also allow her to change the room temperature to prevent hypothermia, (3) since a person with C5-6 quadriplegia has difficulty maintaining a normal body temperature.

(2) In addition, it will provide her with the means to dial a phone by using voice commands in the event of an emergency. (3) Because of her condition, this system will increase her functional capabilities and decrease her need and use for a personal care attendant.

Ms. Doe needs this system immediately. She is not going to recover nor regain any of her functional ability due to her disabling condition which occurred nine years ago. I recommend that Advanced Speech Interface Systems, Inc., provide this system. (2) This company has been in this field of expertise for ten years. They are a recognized medical assistance provider, and the medical community supports them. (5) The system provided by Advanced Speech Interface Systems, Inc., will be customized to Ms. Doe's medical needs. (6) Because this system will be specifically catered towards her health needs, it represents an effective and appropriate use of program funds.

If you have any questions, please contact me.

Philip Physician, M.D.
Physical Medicine and Rehabilitation Specialist
Address
Phone #

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