Microsoft Word - IBD sgi Letter of Medical Necessity-final.DOC

SAMPLE LETTER OF MEDICAL NECESSITY

FOR PROMETHEUS

IBD sgi Diagnostic™

(Please customize based on your patient’s medical history, treatment experience, and/or claims adjudication)

<DATE>

Medical Director

Insurance name

Insurance address

Insurance city, state zip code

Patient: Patient Name

Date of Birth : Patient Date of Birth

ID Number: XXXXXXXXXXXXX

Date of service: XX/XX/XXXX

Provider: Physician Name, MD

Claim Number: 111111 (If available)

Dear [Medical Director]:

I am writing to request full coverage or at least in-network benefit coverage for the diagnostic test PROMETHEUS

IBD sgi Diagnostic™ for my patient [patient name]. I am [patient name] physician practicing at [facility name] in

[city, state]. I consider this test a medically necessary step in the diagnosis and treatment of my patient. My patient

has a history of [diarrhea, GI bleeding, and nonspecific enteritis].

(List information relevant to the patient’s symptoms, treatment and test results if applicable. Address each

reason for denial or unacceptable payment listed on the EOB. Reasons may include:

 Laboratory testing considered experimental

 Out-of-network deductibles/rates applied

 Laboratory services available through a capitated laboratory

 Laboratory testing not considered medically necessary

Include a copy of the patient’s chart notes when applicable.)

I chose Prometheus to perform the IBD sgi diagnostic test instead of an alternative in-network laboratory test

because Prometheus is the only laboratory that offers a diagnostic test that combines serologic, genetic, and

inflammation markers. It also uses a proprietary Smart Diagnostic Algorithm to assist me in differentiating between

IBD vs. non-IBD and CD vs. UC in one comprehensive blood test.

Other potential reasons:

 I directed my patient to utilize an in-network laboratory, but [his/her] blood sample was referred to

Prometheus without our knowledge.

 There is not an in-network laboratory near my patient that refers this test or is able to provide comparable

testing. I’ve included information about Prometheus and several scientific references validating the

performance and value of PROMETHEUS

IBD sgi Diagnostic™.

Please approve full coverage for the PROMETHEUS

IBD sgi Diagnostic™ or at least apply in-network benefit

coverage waiving all out of network deductibles for laboratory testing.

Thank you for your prompt attention. I look forward to receiving a written response from you within two weeks.

Please contact me at XXX-XXX-XXXX if you require any additional medical information concerning patient name.

Sincerely,

Physician name, MD

Facility name

Facility address

Facility city, state zip code

Facility phone number

Attachments: