Letter of Medical Necessity

Letter of Medical Necessity

A Letter of Medical Necessity to a health insurance carrier or Medicare should be clear, concise and focused. The purpose is to present a credible argument as to why the carrier should cover the device. The argument should focus on the specific needs and medical condition of your patient as well as how the device will assist the patient in their home. It should state how and why the LegSim device is superior to other available walking assist devices (crutches, walkers, wheelchairs and prosthesis). It should clearly state why other devices either have not been successful or are not appropriate to use with this specific patient.

The design of the LegSim promotes mobility and a more upright life style. Its size and weight makes it more easily transported than a wheelchair. The simplicity of use lends itself well to movement during emergency situations where a wheelchair can be problematic. Early adoption of the device soon after surgery should minimize muscle atrophy, decrease recovery times, shorten hospital length of stay, and ultimately improve patient outcomes. The ability to modify the device for patients with other complex medical needs further widens its applications.

You may be eligible for reimbursement if you're in the VA System, or have a compensation claim. Medicare and health insurance carriers are also eligible with a letter from your doctor stating that you have a medical necessity, using the code L 5 9 9 9.

It would be important to refer to the LegSim as a SUPPLEMENT to, not a REPLACEMENT for, an existing prosthesis UNLESS the patient will not be using a conventional prosthesis ever again. Hartford Walking Systems would like to offer our expertise and assistance in helping you craft an effective and appropriate Letter of Medical Necessity for your patient.

The letter should include certain general comments about the LegSim device which would be informative to the Medical Director of the Health Plan. These include:

     A. The LegSim device provides patients a more independent, upright lifestyle allowing patients to view the world at "eye level."

     B. The LegSim device is designed for patients who are unable to use prosthesis for various reasons.

     C. The LegSim device increases a patient's mobility helping to limit muscle atrophy, weight gain and other complications of a sedentary lifestyle (diabetes, DVT, or depression).

     D. The LegSim will enhance a patients sense of independence which improves their overall feeling of well-being.

The letter should also include specific information describing why the LegSim device is uniquely suited for your patient's specific medical needs and clinical condition. This section should include the co-morbitities that may preclude the use of crutches or limit the effectiveness of a wheelchair or prosthesis. These could include:

     A. The LegSim is uniquely suited for patients who are unable to use a traditional prosthesis because of:
           a. Heterotopic Ossification (HO) causing improper fitting of the prosthesis
           b. Neuroma of the stump which cause pain and inability of patients to wear a prosthesis
           c. Improper fitting of the prosthesis because of weight gain, stump breakdown or phantom pain

     B. The LegSim device is uniquely suited for patients who can not use traditional crutches because of:
           a. Shoulder injury or rotator cuff problems
           b. Upper extremity paralysis or hemi paresis secondary to stroke
           c. PIC line placement
           d. Brachial plexus injury

The Letter of Medical Necessity should also include specific reasons why the LegSim device would be useful in the context of the patient's home situation performing activities of daily life. These include:

     A. The LegSim device is uniquely useful for patients whose home has narrow corridors and hallways limiting the usefulness of a wheelchair.

     B. The LegSim device is uniquely useful for patients whose house has many stairs or lives in a split-level house.

     C. The LegSim device allows quick and easy exit from a home during an emergency situation.

     D. The LegSim device allows patients to stand stationary while using both hands for activities of normal daily life.

The letter should also include the LegSim web site which provides additional information including video of patients using the device in various life situations. The site can be accessed at www.LegSim.net which will link the user directly into Hartford Walking Systems.

If the carrier renders a denial decision, a letter of appeal is always a reasonable next step. In the second letter specific information on the experience of the LegSim with other regulatory agencies and health insurance carriers would be important to state. Although this information may support your argument, regulatory approval does not guarantee reimbursement. Important information to cite in the appeal letter would include:

     A. The LegSim is an FDA listed device under the code of ITJ, which is a unique prosthetic code that does not compete with any other prosthetic code.

     B. The LegSim has been prescribed at Walter Reed Medical Center through TRICARE and for retired veterans at various VA hospitals using the code of L 5 9 9 9.

In closing, an effective Letter of Medical Necessity should provide information tailored to your patient's specific clinical condition while reinforcing the utility of the device as it relates to the performance of activities of normal daily life. If I can be an additional assistance, please free to contact me at docjat@hartfordwalkingsystem.com.

John A. Tata, MD
Medical Director
Hartford Walking Systems