Letter of Medical Necessity 101

There are many wonderful developments in our modern world that enhance the quality of life for special needs youth. Access to these tools can be a huge barrier for many children, which is of course the basis of our programming!

Insurance can help many families access some of these enhancements, and many are unaware that denied covered isn’t necessarily a dead end. Enter: Letter of Medical Necessity (LOMN).

How is “medical necessity” defined?

By definition, a Letter of Medical Necessity (LOMN) is a document from your licensed healthcare provider that recommends a particular treatment, product or equipment for medical purposes. A letter of medical necessity can be used for reimbursements of medical procedures, supplies, or equipment when you use a health savings account (HSA) or flexible spending account (FSA).

Health insurance covers a wide range of services and products, from doctor visits to hospital stays, prescription drugs to medical devices. But in some cases certain exercise equipment, vitamins, supplements, and other therapy are not covered by insurance. In these instances, individuals can use their health savings account (HSA) or flexible spending account (FSA) to pay for medical expenses not covered by health insurance, if approved by the IRS. If your medical expenses are not considered qualified, a letter of medical necessity verifies with insurance companies and the IRS that your products and services are necessary for your health.

How is “medical necessity” determined?

Medical necessity is difficult to define, as there are as many interpretations as there are payers. In general, medical necessity refers to a decision by your health plan that your services, treatment, product, or equipment is necessary to maintain or restore your health or to treat a diagnosed medical problem.

Medicare, for example, defines medically necessary as: “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.”

What are some occupational therapy services or products that require a letter of medical necessity?

For occupational therapy services, insurance providers are looking at if the treatment is medically appropriate based on the individual’s condition.

A few examples of services or products that may require a letter of medical necessity include:

• Bath lift
• Bed pan
• Braille Teaching Texts
• Motorized Wheelchairs
• Parallel bars

See a complete list of things that may require a letter of medical necessity.

Don’t miss out on needed products and services that benefit your health

When it comes to therapy, access to equipment and supplies needed to make therapy the most beneficial for your healing and health is crucial. A letter of medical necessity from your occupational therapist can help you get access to needed gear. Always ask your therapist if you have concerns about your insurance covering a certain prescribed medical procedure, supply, or equipment for your therapy.

Smile A While Foundation is working to improve access to occupational therapy for special needs children in Jamaica
We are working hard to increase access to the medical procedures, supplies, or equipment needed to support therapy for special needs children in Jamaica and beyond. With that we also work hard to spread awareness and education of occupational therapy to professionals in Jamaica.

Help improve access to occupational therapy for special needs children in Jamaica with your donation to Smile A While today at smileawhilefoundation.org/donate