Letters of Medical Necessity for inpatient hospitalization or treatment

A letter of medical necessity for inpatient hospital treatment must be complete, but it should be brief and focused toward the goal of obtaining funding for the treatment needed.  It is invalid unless it is signed by a “licensed practitioner of the healing arts.”  That would be a physician, not necessarily a psychiatrist, when the prescribed treatment is an inpatient hospitalization.  The doctor needs to affirm that:

  • he/she examined the child face-to-face personally (noting the date, location and duration of the examination is not a bad idea) and summarizing the findings of that examination.
  • he/she is familiar with the child’s history (and summarizes that history briefly, including the date when he/she first met with the child and discussed the child’s situation with his/her caretakers).
  • he/she believes “to a reasonable degree of medical certainty” that the child’s condition requires inpatient hospitalization in order to be treated properly, ethically and efficiently.
  • he/she should render a diagnosis of the child’s condition (with the corresponding code(s) and prescribe a specific treatment (with applicable ICD-9 or ICD-10 codes).
    • Mental illnesses should be diagnosed on all five Axes of the DSM-IV TR criteria (DSM-5 which was released in May of 2013 is being widely criticized so use of DSM-IV Text Revision continues to be accepted widely, especially because of its retention of the Global Assessment of Functioning (GAF) scale which allows a rapid “global” classification of the severity of the child’s condition).
    • Physical illnesses should be included on Axis III of the preceding diagnosis if they are suspected of having influence upon the mental disorder (e.g., medication problems that need to be sorted out)
  • The doctor’s prescription should be rendered for the following purposes (the doctor should state these purposes in writing as the rationale for his/her prescription):
    • to prevent the worsening of the child’s condition,
    • to implement successful  treatment for the child’s condition in the least-restrictive setting in which the treatment can be ethically and professionally delivered, and
    • to prevent the condition from interfering with the child’s ability to maintain functioning.
  • The doctor has to sign the letter personally.
  • It should be dated within 30 days following the doctor’s last face-to-face examination of the child.

Hope this helps.

Steve

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