A Winning LMN: Letter of Medical Necessity for Equipment
I recently wrote about current research describing the unfulfilled therapy and equipment needs for children with special health care situations. Sadly, young children with the most significant impairments were the most impacted by these unmet needs, and I see it daily in my clinical practice. I also described the frequent joys of my job when I am able to help a child or young adult obtain a needed piece of equipment which helps them participate in life. Love to see the first independent exploration in a walker or gait trainer or wheelchair for a child who previously saw the world only passively because of their limited mobility. Those first steps, that first spin in a circle, the first chance to seek out a favorite toy or book or person on their own – priceless.
But the process of obtaining these vital pieces of equipment can be long, arduous, and costly. I usually explain to parents that this process can take as long as 3 to 6 months. Needless to say, they often are discouraged since we’ve just told them their child would benefit from this equipment, yet the cumbersome process will take time – they want it NOW. I do, too.
The undertaking includes the first step decision to consider a piece of equipment, the research regarding options and appropriate sizes, appointments to trial pieces being considered, decisions between family, therapists, and equipment vendors as to the final components (and color choices!), and then, finally, the quote is generated.
This is really only the first part of the process.
Next, the therapist, in collaboration with the physicians, needs to generate an “LMN,” a letter of medical necessity outlining in great detail why this recommended equipment meets “medical/therapeutic goals” specifically for this child. This is where the greatest challenge lies.
Sing the Alphabet Song along with me:
I so remember when my toddler twins (and many of my patients) thought “LMNO” was one letter of the alphabet! But the LMN lives and is a necessary task in my pediatric physical therapy world – therapists often want to avoid the LMN. Let’s see if we can make it easier for all.
What key information needs to be included in an LMN to make that documentation effective so that the reviewer is convinced of the “medical necessity” first try? How can we make the process time efficient and cost effective?
Here are some important components to understand and include in a “winning” LMN:
1. Understand what “medical necessity” means from the perspective of the funding source.
Each insurance policy will document a specific definition as their gold standard for “medical necessity.” Ideally, the family and/or therapist has access to the policies and time to review them – this is important as some policies have blanket statements (“we do not cover special beds” or “gait trainers are not provided for people over 21” – real examples from my experiences) or base a policy based on old or limited research. You may need to address these points directly and share more current and appropriate research. Search for the policy via the Internet or ask the family for a copy of their specific benefit plan.
In general, “medical necessity” basically means that the equipment in this case is expected, based on your clinical judgment and current research, to:
Prevent the onset of an illness, condition, or disability that this specific patient is at risk for, given his/her medical situation
Reduce or ameliorate the physical and functional impact of this person’s illness, condition, or disability
Assist the child/adult to achieve or at least maintain their potential maximal level of function in performing the daily tasks or activities important for their specific, age-related activities, in their multifacet roles as child, family member, student, community members and more.
But wait. Notice that “medical necessity” does not include ease of care for the parents (considered “convenience”) or to prevent or minimize the risk of injury to a caregiver. Nor do insurances typically consider leisure or recreational activities as “medically necessary” unless you link them to impairments and function. Let’s broaden their perspectives!
2. Focus on the facts:
Paint a clear and concise picture of the child’s specific situation and challenges they are facing on a daily basis. Make sure to include their:
- any comorbidities that complicate their picture
- pertinent background medical information
- age, height, weight, and other key measures related to the piece of equipment (leg length, axilla to heel length for standers, sitting height for chairs)
- specific impairments and describe how each impairment causes or place the child at risk for a decreased level of function
- current level of function without the recommended equipment
- Clearly relate the child’s needs specifically to the function of the equipment, the impact on the daily life of the child, and how the equipment will improve that child’s daily function and level of independence
3. Make sure to:
- Write clearly, concisely, and in easy to understand language. The reviewer of your letter may not be a therapist or even a physician or nurse experienced with children with special needs. Avoid PT-specific terminology or acronyms and state the obvious.
- Use lists and bullet points when able to make the document visually attractive and not overwhelming.
- Include a glimpse into your comprehensive clinical decision-making process – what alternatives were considered and why were these alternatives not appropriate or inadequate? Payers particularly want to know if less expensive forms of the equipment were considered and why they are not, in your judgment, appropriate.
- Justify the size parameters of your equipment – insurance payers want to know that we have considered the potential growth of the child for the next 5 years, typically. So that piece of equipment you are proposing for a 3-year-old in preschool potentially has to fit and be appropriate until the child is 8 years old or in ~ third grade. Do your research! We do want to be good stewards of the funding resources and equipment.
- Describe the potential long-term benefits that can occur from usage of,this specific piece of equipment: the effect on impairments, bone density, joint mobility/formation/stability (HIPS!), strength and endurance, postural control, health, and so much more.
- Provide product details – include a link or attach documentation with the equipment specifications to show you are choosing for current and future sizing – “5 years rule” acknowledged.
- Include, if possible, photos or links to videos of the individual, with before and after equipment comparisons. I had one reviewer argue with me that a child with a specific syndrome “couldn’t possibly walk” until he opened the video link with the child successfully walking in the gait trainer during our clinic trial with the equipment. You will need parent permission for this and a HIPPA compliant platform.
- Attach or link to any relevant or current evidenced-based research that applies to this scenario. Insurance benefit policies have been changed successfully when decisions have been appealed and the research has been updated for reconsideration. TN has recently started covering standers again, thanks to grassroots efforts by therapists, supported by current research. With diligence, we can change policies for better outcomes for our patients.
- Check out the product’s website for sample LMN letters specific to their equipment that you can use as a guide. Be sure to check that the info is pertinent to your scenario.
- Start a template or other means to curate research articles that you can copy and paste into your LMN documents when needed.
- With your local equipment vendor, sign up for LMN Builder, a brilliant, free-for-therapists website that provides a basic framework or template that you can use to write your own LMN. The tool remembers your client’s background history to reuse for future LMNs and links equipment to manufacturer’s descriptions that you can further modify. It also includes a comprehensive assessment tool, allows links to products and research, and can include photos or videos. Somewhat of a timesaver, but mostly a comprehensive tool that makes sure I cover everything adequately and don’t forget a small necessary piece that needs to be included or the letter goes straight to denial.
What hurdles or hoop jumping do you face in designing a letter of medical necessity in your clinical practice?
What tools have you found that are helpful?
How do you write LMNs in an efficient and timely manner, balanced with clinical demands?
Now, go celebrate those wins when you hear, “approved for funding.” YES!