Letter of Medical Necessity for Gait Trainers and Standers

Question

Answer

It is first important to make sure that you know your funding sources and what your funding sources cover. I can't say that enough to people and I feel it is important to cover what is meant by least costly alternatives. It's a provision in the health insurance policy that states that they will cover the least expensive device when multiple options are possible. You need to follow the flow of appropriate devices which is what they call it. If there are multiple similar items of the same type of device (gait trainers or standers), as the therapist you need to determine what features the client needs and you need to try the least costly alternative first. You need to rule out why that does not medically meet their needs if it does not meet their needs.  it is my responsibility to have the conversation with the patient/parents to say, well, this is the least costly alternative. This is the one that your insurance company is going to cover. If you want to pay for this one out of pocket because you like it better, you can do that. That can be a tough conversation sometimes, but if there's a reason, by all means, we justify it. For example, this one has a headrest, but this one doesn't; this one goes taller and this one doesn't. We need this one to be wider, this one isn't wide. If there's a reason, list it and you're golden. But, if there truly is no reason and A and B provide the same support and it really just is that somebody likes A better, but A is more expensive than B, my hands are tied, the vendors' hands are tied, this really is what the insurance company is going to pay for. 

For the letter of medical necessity you need to include the following: 

• Least costly and safest as mention
•  Justify each support as needed
  • Example: “In addition to improving ambulation skills to perform Activities of Daily Living, and providing an opportunity for exercise, the recommended ______gait trainer has numerous essential health benefits as well as providing support for Alex in standing to maintain his joint, muscle as he presents with bilateral tight hamstrings, bone and skin health.” 
• State trials and success for equipment
• State why it is MEDICALLY necessary- just as you would in a wheelchair justification
• If the piece of equipment requested is not the least costly, clearly state why it is needed.
  • This one has more supports
  • Size
  •  Why others would not be safe. 

Try to avoid check box template forms or impersonalized form letters, especially manufacturer generated.

Critical to personalize each request to the individual and to what the insurance company requires. 

It is the job of the writer to clearly convey a story or “paint a picture” to the reviewer. They should be able to clearly visualize who the person is, what they need, and why by the end of your letter.

This Ask the Expert is an edited excerpt from the course, Standers and Gait Trainers 101 presented by Lindsey Veety, PT, DPT, ATP/SMS