[Date] [Payor Name] [Payor Address] [City, State Zip] [Patient Name] [Insured‟s Name] [Insured‟s ID] Dear Claims Representative: I am writing to document the medical necessity of NovaVision Vision Restoration Therapy (VRT) for [patient]. This letter provides information about the patient‟s medical history and the prescribed treatment, and serves as a request for consideration of coverage for VRT for the following diagnoses: [Medical Diagnoses, appropriate ICD-9 Dx Codes] MEDICAL HISTORY: [Patient], a [age/gender], suffered a [stroke/TBI] on [date] which has resulted in a defect within the visual field. The loss of vision has caused many difficulties for the patient, including challenges with [reading/grooming/ increased injuries from falls/socializing/etc.] and the inability to perform other activities of daily living. Diagnostic testing results showed the visual field could improve through Vision Restoration Therapy. This patient, according to the 1999 American Medical Association “Definition of Medical Necessity,” qualifies for medically necessary VRT. TREATMENT: NovaVision Vision Restoration Therapy is a daily rehabilitation therapy that can help restore lost vision caused by stroke or acquired brain injury. The patient‟s visual field is mapped and an individual therapy is created to target the region between the seeing and non-seeing areas in his/her visual field. The therapy is performed on an FDA-cleared medical device that delivers progressive levels of individualized stimulation that are evaluated and updated on a monthly basis. Therapy is typically performed twice-daily, six days per week for approximately six to nine months at the patient‟s home. It is, therefore, medically necessary for [patient] to undergo six months VRT. I write this letter for review of benefits under [patient„s ] plan for the prescribing of VRT that is therapeutic. If you require any additional information, please contact me at [phone number]. Sincerely, [Name] [Title] [Clinic] Sample Letter of Medical Necessity to Insurance Company
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