Template Letters | Physician Statement of Medical Necessity
(Submit to Payer with Request for Prior Authorization or Claim)
This letter is only an example. Please edit the letter to suit your needs and replace [bold]
sections with the appropriate information. The patient should keep an original signed copy for
their records.
[PRINT ON MEDICAL CENTER OR INSTITUTION LETTERHEAD]
[TODAY’S DATE]
[INSURANCE COMPANY]
[ADDRESS]
[PHONE/FAX]
Re: [PATIENT NAME, DOB]
[MEMBER ID]
Dear Claims Representative:
I am writing on behalf of my patient, [PATIENT NAME AND POLICY NUMBER], to request that
[NAME OF HEALTH INSURANCE COMPANY] approve coverage for [EXPLANATION OF THERAPY,
TREATMENT, SERVICE, ETC.] in relation to their diagnosis of [PATIENT DIAGNOSIS].
This letter provides information regarding this patient's medical history, diagnosis, and treatment
plan and confirms the medical necessity and appropriateness of this prescribed treatment.
Pulmonary hypertension (PH) is a rare condition characterized by increased blood pressure in the
pulmonary artery. When pulmonary hypertension occurs in the absence of a known cause, it is
referred to as Idiopathic Pulmonary Hypertension (IPAH). IPAH is extremely rare, occurring in
about two persons per million populations per year. Secondary pulmonary hypertension (SPH) is
commonly caused by breathing disorders such as emphysema and bronchitis. Other causes may
include scleroderma or CREST syndrome. Pulmonary hypertension is an incurable and
progressive illness with few treatment options. (Insert name of treatment) has been shown to
significantly improve prognosis.
Patient's History and Diagnosis
[INSERT INFORMATION REGARDING PATIENT'S HISTORY WITH THIS DISEASE, INCLUDING
PREVIOUSLY ATTEMPTED TREATMENTS AND RESULTS.]
www.PHAssociation.org/patients/insurance/letters
Based on the above information, please provide coverage for these submitted charges. This
[TREATMENT/SERVICE] is medically necessary for this patient in order to treat [HIS/HER]
diagnosis. If you require any additional information, please contact me at [INSERT PHYSICIAN'S
TELEPHONE NUMBER AND CONTACT INFORMATION].
Sincerely,
[SIGNATURE]
[PHYSICIAN NAME], [DATE]
[ADDRESS]
[PHONE NUMBER]
[FAX NUMBER]
www.PHAssociation.org/patients/insurance/letters