FSA Letter of Medical Necessity Template

Letter of Medical Necessity Dr. Eleanor Vance, GP City General Practice 23 High Street, Anytown AB1 2CD, 01234 567890 1 November 2024 RE: Letter of Medical Necessity – FSA/HSA/HRA Reimbursement To Whom It May Concern, I am writing to certify that I am the treating clinician for Mrs. Clara Jenkins (DOB: 15/03/1970, Patient ID: CJ700315), and to confirm that the following treatment, product, or service is medically necessary based on my clinical evaluation. The patient has been diagnosed with Chronic Migraine without aura (ICD-10 G43.109). This diagnosis is supported by the patient’s clinical presentation and relevant medical history. I have recommended the following treatment, product, or service: Cefaly Dual device for acute and preventative migraine treatment. This device provides transcutaneous supraorbital neurostimulation (tSNS). This recommendation is medically necessary for the treatment, management, and/or prevention of the patient’s condition. It is not intended for general health maintenance, wellness, or cosmetic purposes. The recommended intervention is expected to provide clinical benefit by addressing the underlying condition and/or associated symptoms. The expected duration of this treatment or use of this product/service is ongoing, for daily preventative use and as needed for acute migraine episodes. Additional relevant clinical information includes: Mrs. Jenkins has a 10-year history of chronic migraines, experiencing 15+ headache days per month, with significant impact on her quality of life and daily functioning. She has failed trials of several oral prophylactic medications including Topiramate and Propranolol due to intolerable side effects and lack of efficacy. Non-pharmacological interventions such as lifestyle modifications and stress management have been attempted with limited success. The Cefaly device offers a non-pharmacological, evidence-based alternative with a favourable side effect profile, making it a suitable option for her refractory migraines. I certify that the above information is accurate to the best of my knowledge and that this treatment, product, or service is medically necessary as defined under applicable medical and regulatory guidelines, including IRC Section 213(d)(1). If further information is required, please do not hesitate to contact my office. Sincerely, Dr. Eleanor Vance, GP, GMC No: 1234567, 1 November 2024