Nr 2: Letter Of Med Necessity

Front 1

It's an addenum to Summary Report/Narrative.

1. Indicates specific diagnosis (ICD)

2. The specific treatment needed (CPT)

3. Length of treatment

4. How this tx will alleviate the medical condition?

Lists the amount, number, and duration for preauthorization.

Back 1

Letter of Medical Necessity (LMN)

Front 2

What are the 3 subcategories for a complete eye exam (CEE)?

Back 2

3 main categories for CEE:

1. Refractive Error
- includes accommodation

2. Binocular Status
- includes oculomotor

3. Ocular Health
- with & without DFE

Front 3

It's an evaluation of the function of the ocular muscle system.
- This testing may include but is NOT limited to, qualitative & quantitative testing of ocular motility, accommodation, & binocular function.

Back 3

Sensorimotor examination

Front 4

How would you test a patient's qualitative and quantitative testing of ocular motility, accommodation, and binocular function?

Back 4

Sensorimotor examination:

1. To measure OCULAR DEVIATION:

- Use of vertical/horizontal prism bars or hand held prisms

2. To evaluate accommodation:
- use LENSES

3. Test to evaluate eye movements

Front 5

The evaluation may be used when the patient complains of:

1. Double vision

2. Overlapping letters/words when reading

3. Asthenopia/HA when reading

4. Diagnosing strabismus

Back 5

Sensorimotor examination

Front 6

What are some SPECIFIC Tests used in the sensorimotor examination?

Back 6

Examples of tests that would apply:

1. Cover tests with quantification
2. Fixation Disparity/Retinal Correspondence testing
3. Repeated Phoria and Vergence testing (ranges and facility)
4. Fusional testing (Worth 4 dot, VO Star binocular behavior test)
5. Evaluation of Pursuits and Saccades (e.g., computer assisted evaluation of eye movements, developmental eye movement test)
6. Evaluation of Accommodation (ranges and facility)

Front 7

What's CPT 92060?

Back 7

CPT 92060:

Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)

Front 8

What's the difference between:

CPT code vs ICD9 code?

Back 8

CPT code = Procedure code (99212)

ICD9 code = Diagnosis code (367.10)

Front 9

1. Understanding the LAW to insurance coverage:

How does the Beneficiary prove a covered loss by submitting a claim?

Back 9

Beneficiary must prove a covered loss by submitting a claim:

i. The insurer will either pay or deny the claim

ii. If the claim is denied, the insurer must prove loss is excluded from coverage

Front 10

2. Understand the meaning of medical necessity:

a. Each insurer defines the term in a different manner

b. Get the insurance company you are approaching to fax or email their definitions of medical necessity. Study it carefully and be sure to include it in your letter.

Where do you find this info?

Back 10

It will be in the insurer’s benefits booklet:

You will find the definition of medical necessity in the “summary plan description”

Front 11

3. Gear your letter to your audience

How would you do this?

Back 11

a. Paint a picture of the beneficiary and create an understanding of the equipment

b. Use terms that can be understood by an ordinary person who has NEVER worked in health care or heard of the equipment

Front 12

What's the 4th step in the LMN?

Back 12

4. State who you are in the opening sentence, and how long you have treated the patient

Front 13

5. Explain beneficiary's condition?

How would you do this?

Back 13

a. Discuss the impact of the condition on the person’s life noting limitations
without the adaptive equipment or therapy

b. State the obvious: assume insurers haven’t experienced a person with the disabilities you are describing

Front 14

6. Describe the equipment or therapy?

How would you do this?

Back 14

a. Explain how it will improve the beneficiary’s FUNCTION.

b. Explain why alternatives WON'T improve beneficiary’s function

Front 15

7. Explain how the equipment can replace other expenses and is cost-effective?

Back 15

This is critical for equipment that is new and/or more expensive than other accepted alternatives

Front 16

8. Address insurer’s definition of medical necessity?

Back 16

a. Don’t go overboard; simply state that the policy requires that the equipment or therapy meets certain criteria in order to be considered medically necessary

b. Provide a one-sentence explanation of how each criterion is met

Front 17

What's steps 9 and 10 of LMN?

Back 17

9. Make the beneficiary a real person facing a difficult adversity

10. Enclose a copy of the prescription (ie.prism)

https://www.lmnbuilder.com/

Sample Letter of Medical Necessity