SAMPLE LETTER OF MEDICAL NECESSITY - Download as DOC by iuq51574

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									TEMPLATE LETTER OF PRIOR APPROVAL / MEDICAL NECESSITY
Boston Scientific recommends seeking prior authorization for all non-Medicare cases. The
following is a sample letter for consideration by physicians when seeking prior authorization.
Please note that prior authorization is typically not required for Medicare fee-for-service
patients.

PLEASE NOTE: This letter is intended as an example for your consideration and may not
include all the information necessary to support your prior authorization request. Please
note that the requesting facility is entirely responsible for ensuring the accuracy, adequacy
and supportability of all information provided.

{Insert Date}

{Insert Medical Director Name}
{Insert Title}
{Insert Plan / Contractor Name}
{Insert Street Address}
{Insert City, State, Zip}

Dear Dr. {Insert Medical Director’s Last Name}:

Patient’s Name: {Insert Patient’s Name}
Policy Holder: {Insert Policy Holder’s Name}
Policy Number/Social Security Number/Group Number: {Insert Appropriate Number}

Dear Dr. {Insert Physician’s Last Name}:

I am requesting prior authorization and a determination of medical necessity for the above-
referenced {insert either patient or subscriber} who suffers from {insert information about
patient's existing medical condition that would indicate a need for CAS}. It is my intention to
place a carotid stent with embolic protection.

The following is a brief summary of this patient and the technology.

Medical Necessity: My patient is a {insert age}-year old {insert patient gender} who suffers
from {insert information about patient's existing medical condition that would indicate a need
for CAS}. This patient also has {list the symptoms or comorbidities that render your patient
at high risk for CEA}, and is therefore at high risk for surgery. {Please include further
information about the patient here, including current symptoms, attempted treatment, etc.}
Chart notes, angiogram report and duplex ultrasound have been enclosed for your review.

Description of the Procedure: This procedure involves guidance techniques of a
traditional angioplasty. However prior to the angioplasty being performed, a FilterWire EZTM
Embolic Protection System is deployed distal to the area of the stenosed lesion. After the
angioplasty is performed, a Carotid WALLSTENT® Monorail® Endoprosthesis is then placed
in the area of the stenosis and opened to cover the plaque. The distal protection device is
retrieved, to prevent any dislodged plaque material from being left behind.

Please do not hesitate to contact me for further information. I can be reached at {insert
USPV3675.138.0
Template Letter for Medical Necessity
Up to date as of October 8, 2008. Please note that information and the needs of payers change frequently.
                                                    Page 1
phone number and/or email address} if you have any questions. Thank you for your
consideration. I look forward to hearing from you soon concerning this matter.

Sincerely,




{Insert Name of Physician}

Enclosures




USPV3675.138.0
Template Letter for Medical Necessity
Up to date as of October 8, 2008. Please note that information and the needs of payers change frequently.
                                                    Page 2

								
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