Resources for Clinicians: Medical Necessity Letters

A medical necessity letter is “[the] authoritative voice of a psychiatrist [or other clinician], backed by the law, [that] can push insurance companies to do the right thing.” So wrote Mark Moran in the Psychiatric News article “Medical-Necessity Letters Written By Psychiatrists Can Be Decisive.”

Medical necessity letter – template and instructions

Here you can access a Template and instructions for providing a medical necessity letter to your patient.
This article from the Journal of Psychiatric Practice article describes the value of these letters when dealing with insurance companies.

“Why so many appointments?” – Specific medical necessity letter response

Download template letter

The template letter provided here documents the medically necessary treatment plan and approach to patient care. This letter can be prepared by the clinician, saved in the patient’s file, and sent to an insurer in response to their questioning the treatment frequency and/or session duration.

As reported by ProPublica in November 2024), therapists may encounter an insurance “company representative with the Orwellian title ‘care advocate’ [who] would call and grill them about why they’d seen a patient twice a week or weekly for six months.”

Professional guidelines and expert consensus support the value of therapy with frequency and duration suited to supporting a patient towards recovery and maintenance of day-to-day functioning:

“Informed by the robust literature of clinical research, generally accepted standards of care provide guidance for appropriate frequency and duration of out-patient therapy carefully prescribed as appropriate to the patient’s specific clinical condition. Such decision-making is among the most critical responsibilities of a clinician, whether a psychiatrist, psychotherapist, psychologist or LCSW.” Susan G Lazar, MD
“For outpatient mental health services, the treatment plan – from diagnosis, to therapeutic approach, frequency of medically-necessary care, and duration of care — must be aimed at the appropriate clinical goal of recovery. These decisions are commonplace across the wide range of medical, surgical, and mental health care, and are some of the most important ones that treating clinicians make.” Essie Larson, Ph.D., DBT-Linehan Board of Certification, Certified Clinician™
“Clinicians must prescribe the frequency and duration of psychiatric and psychological treatments based on generally accepted medical standards, just as they would prescribe dose and duration of a medication in any other medical specialty. Such practice is essential to maximize clinical outcome across the continuum of care, including inpatient, residential, and outpatient treatment.” Andrew J. Gerber, MD, PhD

Medical necessity letter: success story from Ohio psychologist

“In my work with a young adult who presented complex co-morbidity, I soon recognized that the insurance support available for residential care or intensive outpatient treatment would be insufficient. She and her family were facing yet again another round of protracted battles to eke out meager payments, if any at all. My patient and her family had plenty on their plate and dealing with their insurer was surely more than they needed at that time.

“After receiving the anticipated and unwarranted denial deeming her care “not medically necessary” treatment, I knew that the insurer could not have the last word. My patient, and others like her, deserved better.

“I documented my clinical assessment using the template medical necessity letter provided in a Journal of Psychiatric Practice article authored by Joe Feldman (president of Cover My Mental Health), Dr. Eric Plakun (Medical Director and CEO at Austen Riggs Center) and Mark DeBofsky (litigator and expert in health insurance at DeBofsky Law).

“That medical necessity letter made all the difference for my patient, her family, and for me as the clinician responsible for his care. The insurer reversed their unsubstantiated denial, approving the required care, and relieved the family of an unnecessary burden.”

Michael Groat, PhD
Licensed Psychologist
Linder Center of HOPE