Letter of Medical Necessity


Subject: Need for orthodontic treatment coverage

Dear [Insurance provider name], I hope this letter finds you in good health and high spirits. I am writing this letter to appeal for the coverage of orthodontic treatment, specifically braces, for my patient named [Patient’s Full Name], born on [date of birth]. I believe that this orthodontic treatment isn’t for cosmetic purposes but is medically necessary for the following reasons:

Dental Health Concerns:

[Patient’s full name] has been experiencing dental health issues that can be resolved with the help of braces. The current issues are misaligned teeth, overcrowding, or malocclusion, which can impact his oral health and well-being.

Speech and Eating Difficulties:

The misalignment of teeth contributes to difficulties in speech and eating. Addressing these issues by getting dental braces will not only improve [patient’s full name]’s quality of life but also prevent future complications related to speech impairments and dietary limitations.

Prevention of further complications:

Getting timely treatment at this stage can prevent the development of more serious dental problems in the future. Timely intervention is crucial to avoid complications such as temporomandibular joint (TMJ) disorders, extreme tooth wear, and other issues that may need more extensive and costly treatments.


Our teeth are one of the most prominent features of our face. The poor appearance of one’s teeth can negatively affect a person’s self-esteem and confidence. Correcting the negative appearance of teeth will not only contribute to [Patient’s Full Name]’s physical health but also positively impact her mental and emotional well-being.

I am attaching the relevant dental records, X-rays, and any other supporting documents that highlight the medical necessity of getting dental braces for [patient’s full name]. Also, I kindly request a review of his/her case by your dental review board to consider the full nature of his/her oral health needs.

I understand the need to follow traditional guidelines, and I appreciate your time and consideration in reviewing this appeal. If you require any further information or documentation, please do not hesitate to contact me at [mention phone number] or [mention email address].

Thank you for your prompt attention to this matter.


[Your Full Name]
[Your Title, if applicable]
[Your Dental License Number, if applicable]

Letter of Medical Necessity

Medical Letter Template #1



Subject: Appeal for Coverage of Laser Eye Surgery for Vision Correction

To Whom It May Concern

I hope this letter finds you in good health. I am writing this letter to formally request the coverage of my laser eye surgery, specifically for vision correction, as a policyholder under the policy number [Your Policy Number].

For the past year, I have been experiencing very blurry vision. After I went to an ophthalmologist, he diagnosed the condition as astigmatism. My ophthalmologist, Dr. [Doctor Name], has recommended laser eye surgery as a successful and medically necessary solution to address my vision issues caused by astigmatism.

The procedure, known as [name of the laser eye surgery procedure, e.g., LASIK or PRK], has been deemed suitable for my condition after thoroughly examining my eye health and consultation with Dr. [Doctor’s Name]. The surgery is said to correct my astigmatism, improve my eyesight, and enhance my overall quality of life.

I have tried to wear contact lenses for my vision but found them uncomfortable. I understand that according to my insurance policy, the coverage for elective procedures, which in my case is laser eye surgery, may be subject to specific terms and conditions. However, please understand that this is the only option and a medical necessity for my vision correction. This will also eliminate my need for and dependence on corrective lenses. I kindly request a review of my case.

I have attached relevant medical records, including Dr. [Doctor Name]’s recommendation, diagnostic reports, and all other supporting documentation that seemed necessary for your assessment. I request that you kindly speed up the review process and provide me with information regarding my proposed laser eye surgery coverage.

If there is any additional form or procedure required according to the insurance policy, please do not hesitate to inform me. I will promptly reply and provide what is needed. I am more than willing to provide any further documentation or information needed to support this request.

Thank you for your prompt attention to this matter. I look forward to a positive reply and appreciate your consideration of the request for my much-needed laser eye surgery.


[Your Name]
[Your Policy Number]
[Your Signature, in the case of a physical letter]

Letter of Medical Necessity

Medical Letter Template #1

You may also like...