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SAMPLE LETTER OF MEDICAL NECESSITYDatePayer AddressRe: [Insert patient name and subscriber number]Dear Dr. [Insert name of Medical Director]:Please consider this letter a request for preauthorization of benefits to treat my patient, [insert patient name], who suffers from [insert patient ICD-10-CM diagnosis code(s) and description of procedure]. It is my clinical judgment that [insert patient name] is a candidate for [insert proposed procedure and ACell product]. Prior to scheduling this procedure, I am seeking preauthorization and predetermination of benefits for my patient. Patient History [Insert patient name] presented to me with complaints of [insert detailed patient history with description of patient’s current condition including diagnosis, length of time problem has existed, current/ongoing complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life].Previous treatment efforts include: [indicate procedures, medications, and/or therapies attempted - include outcome of each treatment]. Despite these treatments and therapies, [insert patient name] has experienced no significant response from [insert specific information about the response to treatment and/or attach medical record documentation, pictures, etc. here]. A problem-focused history and exam was performed as well as [indicate diagnostic tests such as ABI, conservative treatments that were provided and failed that support treatment, etc.]. This information, together with the attached patient record documentation supports my request for treatment. Proposed Treatment[Insert description of proposed procedure]. This procedure will be performed on [indicate anticipate date of procedure] at [indicate site of service and name of practice or facility where the procedure will be performed – office, ambulatory surgery center, outpatient hospital, inpatient hospital]. Please confirm if there are any restrictions on performing this procedure in this setting. Coding I anticipate performing procedures and using products identified with the following codes for the procedure:CPT Codes HCPCS Codes ICD-10-PCS Procedure Code(s) [Inpatient Only] Please confirm this procedure will be covered for [insert patient name] based on medical necessity. Please contact me at [insert phone number] if you have any questions. Sincerely, ................
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