1. [Date]
[Dr. Name]
[Practice Name]
[Address]
[City, State, Zip]
Regarding:[Patient Name]
DOB: [00/00/0000]
Policy #: [ABC123456]
Dear [Name of Insurance]Representative,
I am writing on behalf of my patient, [Patient Name], to documentmedical necessity for [Medication and
Strength]. This letter providesinformationonthe patient’scondition, medical history, andtreatment
rationale, demonstratingthemedical necessity for the medication.
[Medication Name]is indicated for controlling intraocularpressure. [Patient Name] is being treated for
low tension Glaucoma(diagnoses code 365.12)asof [00/00/00]. [PatientName] requires the use of
[Medication Name]twice a day in botheyes. With the use of [Medication Name], the patient’sintraocular
pressure hasbeen reduced by anaverage of [%] in each eye.
Given the patient’sconditionandthe effectiveness of [MedicationName], I recommendthe continued
use of this Glaucoma medication. Inmy professionalopinion, [MedicationName] is medically necessary
anda clinically appropriatemean of treatmentfor thispatient. If youhaveany questionsorrequire
additionalinformationregarding this patient’streatmentplease contact me at [physician phonenumber].
Sincerely,
[PhysiciansName], M.D.
![[Date]
[Dr. Name]
[Practice Name]
[Address]
[City, State, Zip]
Regarding:[Patient Name]
DOB: [00/00/0000]
Policy #: [ABC123456]
Dear [Name of Insurance]Representative,
I am writing on behalf of my patient, [Patient Name], to documentmedical necessity for [Medication and
Strength]. This letter providesinformationonthe patient’scondition, medical history, andtreatment
rationale, demonstratingthemedical necessity for the medication.
[Medication Name]is indicated for controlling intraocularpressure. [Patient Name] is being treated for
low tension Glaucoma(diagnoses code 365.12)asof [00/00/00]. [PatientName] requires the use of
[Medication Name]twice a day in botheyes. With the use of [Medication Name], the patient’sintraocular
pressure hasbeen reduced by anaverage of [%] in each eye.
Given the patient’sconditionandthe effectiveness of [MedicationName], I recommendthe continued
use of this Glaucoma medication. Inmy professionalopinion, [MedicationName] is medically necessary
anda clinically appropriatemean of treatmentfor thispatient. If youhaveany questionsorrequire
additionalinformationregarding this patient’streatmentplease contact me at [physician phonenumber].
Sincerely,
[PhysiciansName], M.D.](https://image.slidesharecdn.com/84a3ff3c-556c-42ff-b088-973887dafdc1-150812210059-lva1-app6892/85/Letter-to-insurance-company-for-medication-1-320.jpg)
