Letters of Medical Necessity

Insurance Preauthorization Information for Providers
In Utah, Medicaid implemented a policy in July 2007 which has required obtaining preauthorization for most genetic testing. Many insurance companies are also requiring such preauthorization.
Medicaid has suggested some procedures that will hopefully expedite this process, including:
  • a faxed letter stating the medical necessity of the test, and how knowing the test results will impact patient care;
  • supporting literature if available; and
  • the name of the doctor (and contact information) requesting the preauthorization.
Below you will find sample letters of medical necessity for a variety of conditions and related testing/treatment. These should be adapted to reflect the specifics of your patient and tests/treatment requested. As many of these letters are copies of the original with identifying data deleted, you will notice that several are for more than one test and are listed under each test included in the letter. Letters in Word format may be edited directly with your own demographic information before printing. Some insurance contracts may require a geneticist or other sub-specialist to authorize these tests.
See also Insurance Preauthorization for Diagnostic Test Form (University of Utah) (Word Document 46 KB) for information for families on insurance preauthorization.
Related Therapies, testing
Literature backing up need for tests, treatment
[Curry: 1997]
[Shevell: 2003]
[Moeschler: 2006]
[Szymanski: 1999]
[Luby: 2006]

Page Bibliography

Curry CJ, Stevenson RE, Aughton D, Byrne J, Carey JC, Cassidy S, Cunniff C, Graham JM Jr, Jones MC, Kaback MM, Moeschler J, Schaefer GB, Schwartz S, Tarleton J, Opitz J.
Evaluation of mental retardation: recommendations of a Consensus Conference: American College of Medical Genetics.
Am J Med Genet. 1997;72(4):468-77. PubMed abstract / Full Text
A consensus statement regarding a rational clinical approach to a child with mental retardation including history, physical exam and recommended testing.

Luby J, Mrakotsky C, Stalets MM, Belden A, Heffelfinger A, Williams M, Spitznagel E.
Risperidone in preschool children with autistic spectrum disorders: an investigation of safety and efficacy.
J Child Adolesc Psychopharmacol. 2006;16(5):575-87. PubMed abstract
A randomized placebo-controlled trial showing safety and efficacy for risperidone in preschool children on the autism spectrum.

Moeschler JB, Shevell M.
Clinical genetic evaluation of the child with mental retardation or developmental delays.
Pediatrics. 2006;117(6):2304-16. PubMed abstract / Full Text
This report describes the "optimal clinical genetics evaluation" for children with developmental delay or mental retardation for medical home providers.

Shevell M, Ashwal S, Donley D, Flint J, Gingold M, Hirtz D, Majnemer A, Noetzel M, Sheth RD.
Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society.
Neurology. 2003;60(3):367-80. PubMed abstract / Full Text

Szymanski L, King BH.
Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues.
J Am Acad Child Adolesc Psychiatry. 1999;38(12 Suppl):5S-31S. PubMed abstract
A review of mental health disorders in the DD/MR population. Although possibly more frequent in this population, psychiatric disorders are essentially the same as in normally developing children; however, behavioral observations are very important due to decreased verbal skills in this population.