Letter of Medical Necessity Template

[Instructions: follow individual payers’ requirements for preparing and submitting appeals. Although this template letter is intended to support request of coverage, you may need to comply with payer-specific requirements. Providers are responsible for customizing the letter to reflect the unique background and diagnosis of a particular patient, as well as the special requirements of the particular payer involved. The provider is responsible for ensuring the medical necessity of the procedure.]

[insert date]

[insert Medical Director Contact name] [insert Payer organization name] [insert Street address] [insert City, State, Zip Code]

RE: [insert patient name] Date of Birth: [insert patient’s DOB] Policy ID/Group Number: [insert policy ID/Group number] Policy Holder: [insert policy holder’s name]

To Whom It May Concern:

I am writing on behalf of my patient, [insert patient name] to document the medical necessity of PET imaging using NETSPOT. After radiolabeling with Ga 68, NETSPOT, a radioactive diagnostic agent, indicated for use with positron emission tomography (PET) for the localization of somatostatin receptor positive neuroendocrine tumors (NETs) in adult and pediatric patients. This letter summarizes my patient’s medical history and clinical rationale.

Patient’s History and Diagnosis: [Include information here regarding the patient’s condition, symptoms, and history related to his/her condition]

Clinical Rationale and Supporting Study Data [Include information on the course of care and use of PET to diagnose and stage the cancer before treatment is initiated—see Clinical Summary sheet and FDA Approval Letter]

Summary: Based on a thorough clinical assessment of my patient, imaging with NETSPOT is medically necessary to ensure accurate localization of neuroendocrine tumors. Please contact me if any additional information is required to ensure its prompt approval.

Sincerely, [insert Physician’ s name and signature] [insert Contact Information]