Letter of Medical Necessity Flashcards
who covers it
Documents the medical need for durable medical equipment
Insurance companies typically will not pay for “convenience” items.
The VA and Worker’s Compensation will often pay for equipment that mainstream payors will not.
Many private insurance companies follow Medicare guidelines for DME coverage
definition
services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.
requirements
Paints a picture of the patient and the DME that is needed.
Limit medical jargon/abbreviations
Communicate with patient, family, physician and case manager
what to include
- patient’s current diagnosis, and any other complicating medical issues
- why a lesser piece of equipment will not work or is unsafe.
Ex. To justify a power wheelchair you must rule out the following…walker, optimally configured manual w/c, and a scooter - Clearly define the equipment that you are requesting.
(Include name and model number is possible)
Include any MMT/ROM information or other standardized assessments that will support the equipment need
Use equipment manufacturer representatives as a resource.
Many DME manufacturers have sample LMN on their websites
Needs to be on facility letter head signed and dated by therapist and MD
outline
Describe the type of equipment being requested
State why the device is medically necessary
Describe any evaluations to determine need for DME
Explain that the recommended device is the least costly alternative to ensure medical safety and rehospitalizations
Use the concluding paragraph to restate the main points of the report
Commonly Requested DME
Bathing equipment is rarely covered by private insurance and never covered by Medicare
Worth asking private insurance…all they can say is “no”!
Drop Arm bedside commodes (BSC) are typically covered if the patient is non-ambulatory
Standard BSCs are typically covered by private insurance but Medicare has specific criteria to meet
medicare support group 1
patient is completely immobile. Otherwise, he or she must be partially immobile, or have any stage pressure ulcer and demonstrate one of the following conditions: impaired nutritional status, incontinence, altered sensory perception, or compromised circulatory status. A physician order must be obtained prior to delivery of the equipment and should be kept on file by the supplier
medicare support group 2
A group 2 support surface is covered if the patient has a stage II pressure sore located on the trunk or pelvis, has been on a comprehensive pressure sore treatment program (which has included the use of an appropriate group 1 support surface for at least one month), and has sores which have worsened or remained the same over the past month. A Group 2 support surface is also covered if the patient has large or multiple stage III or IV pressure sores on the trunk or pelvis, or if he or she has had a recent mycutaneous flap or skin graft for a pressure sore on the trunk or pelvis and has been on a group 2 or 3 support surface.
medicare support group 3
– A group 3 support surface is covered if the patient has a stage III or stage IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, the patient is under the close supervision of the patient’s treating physician, at least one (1) month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with patient care, and all other alternative equipment has been considered and ruled out.
tips
If at all possible, have the patient practice/use the equipment that you are recommending
Ask questions of suppliers, therapist, case managers, and manufacturers representatives
Make friends with your suppliers and manufacturer’s reps, they can often get demo equipment for trials and they are aware of any changes to Medicare DME coverage.
