For Lack of Medical Necessity on a Home Care Visit Appeal Letter Free Download


For Lack of Medical Necessity on a Home Care Visit
 Appeal

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Health Symphony Appeal Letter For Lack
of Medical Necessity on a Home Care Visit

Your name and address

Date

Address of Claims review department

RE: Name of Insured:
Plan ID #:
Claim #:

Dear Claims Review Department:

I have received the explanation of benefits for [Patient Name]. However, I believe the charges totaling [charge total] for [Dates of Service] have been considered incorrectly.

The EOB (explanation of benefits) states that the [Date of Service] charge of [Amount] is not medically necessary. When I spoke to the claims center earlier this week, [Health Plan’s] explanation of the denial was because the patient is not home bound and believe the visit was for patient convenience and not medically necessary.

My physician has reviewed the nurse's notes for each skilled nursing visit, and medical necessity appears to have been established. The [Date of Service] visit should not have been denied.

I began a new infusion therapy on that date and I required instruction on drug administration. Skilled nursing visits are necessary to follow up on how well the patient is learning, and indeed, there was an error in my technique. Throughout the therapy I was fatigued, weak and felt sick. I have been overwhelmed by all of the therapies, and I required additional instruction and reinforcement. The results of not having skilled nursing visits could lead to further complications, such as not following the drug schedule or performing inaccurate drug administration.

It appears that a review of the nurse's notes would support the medical necessity of the nursing charges. Please reconsider the denied portion of the charges and issue a payment to [Medical Provider] in the amount of [Amount].

Sincerely,

[Insured’s Name]

Enclosures:
Statement of medical necessity from the ordering physician
The home health care nursing notes