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Letter of Medical Necessity: Cooling Vest

Appeal / Preauthorization / Reimbursement Request


Today’s date ________________________________________

Plan Name/Number __________________________________

Plan Address _______________________________________
                      _______________________________________

 
To whom it may concern:

This is a request for (choose one: appeal of your denial, pre-authorization, reimbursement) of a cooling vest for my patient, (patient name), who lives with (state the medical condition).  I prescribed this specialized garment to help manage and/or relieve the patient of the various symptoms induced or exacerbated by warm environments, including ____________________________________________________________________________________________________________________________.

(Patient name) has sought medical care due to heat-related symptoms on the following occasions: ____________________________________________________________________________________________________________________________________________.

After careful consideration of (patient’s name)’s needs, functional capability and symptoms including (fill in specific details of relevant symptomatology and personal complaints), it is my conclusion that a cooling device would assist in improving (patient’s name)’s overall quality of life as well as functional abilities.

I look forward to, and appreciate, your prompt response in this pressing matter.

Very Truly Yours,

(Physician name and signature)

(Physician contact information)

CC: (patient’s name)

       (patient contact information)

 

  

 


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