Free Letter of Medical Necessity Template

What is a letter of medical necessity?

A letter of medical necessity (LOMN) is a clinical document written by a treating clinician to an insurance company explaining why a specific treatment, medication, service, or frequency of service is medically necessary for a patient. Insurance companies often limit the number of therapy sessions per year, cap medication prescriptions, deny coverage for certain treatments, or require prior authorization before providing benefits. When a clinician believes standard coverage limits do not meet a patient's clinical needs, they write a LOMN documenting the medical justification for an exception or increase in coverage. The letter must demonstrate: the patient's diagnosis and severity, why standard treatment is insufficient, what specific treatment is being requested, clinical evidence supporting the treatment, and the anticipated outcomes if the treatment is provided or the harm that might result if it is denied. LOMNs are often decisive in insurance appeals — they allow clinicians to make the clinical case directly to insurance medical directors. A strong LOMN is specific, grounded in DSM-5 diagnoses and the patient's documented symptoms, cites clinical evidence, and explains the necessity of the requested treatment in clear language that a non-specialist medical director can understand.

What's in this template

This letter of medical necessity template includes:

• Clinician Information: Name, credentials, license number, specialty/discipline, practice name, contact information, date of letter
• Insurance Company Information: Insurance company name, medical director name or title, address, claim or member ID for the patient
• Patient Identifying Information: Full name, date of birth, member/policy number, date of initial evaluation
• Diagnosis: Primary diagnosis with DSM-5 code, severity level, comorbid diagnoses if relevant, diagnostic criteria met, method of assessment used
• Clinical Presentation & Symptoms: Specific symptoms at presentation, severity and functional impact, how symptoms affect the patient's work, relationships, daily functioning
• Current Treatment & Response: What treatments have been tried (medications, therapy modalities, frequency), patient's response or lack of response, why current treatment plan is insufficient
• Specific Request: Exact treatment being requested (e.g., 52 weeks of weekly therapy instead of 20 sessions per year; approval of specific medication; twice-weekly sessions instead of once weekly)
• Clinical Justification: Why this specific treatment is medically necessary for this patient, how it addresses the patient's diagnosis and symptoms, clinical evidence or practice guidelines supporting the request
• Alternative Treatments Considered: What other treatments were considered or tried, why they are not adequate for this patient's specific presentation
• Prognosis with Treatment: Expected outcomes if the requested treatment is provided, likelihood of improvement, anticipated timeline
• Prognosis without Treatment: What happens if the requested treatment is not approved, risks of untreated condition, possible deterioration in functioning or symptoms
• Supporting Evidence: Reference to published clinical guidelines, research evidence, DSM-5 diagnostic criteria, other clinical documentation supporting the necessity
• Clinician Attestation: Signature, date, and credentials affirming that the letter is based on clinical judgment and knowledge of the patient

When to use this template

Use the letter of medical necessity when:

• Requesting increased frequency of therapy sessions beyond insurance coverage limits
• Appealing insurance denial of a treatment, medication, or service
• Requesting authorization for a specific therapy modality not typically covered
• Justifying extended or intensive treatment for complex conditions
• Requesting extended psychiatric hospitalization beyond standard authorization
• Appealing limitations on mental health coverage due to patient's clinical severity
• Requesting authorization for specialized assessment or testing

This template is used by all mental health clinicians (therapists, counselors, social workers, psychologists, psychiatrists) and medical providers across all specialties.

How to use the template with Scriber

Record your clinical documentation and assessment conversation with consent and Scriber transcribes the key information. Rather than reconstructing symptom severity, functional impact, and clinical reasoning from memory, you have a transcript capturing what the patient reported, what you observed, and what clinical concern prompted the LOMN request. Use the transcript to draft the LOMN: extract symptom presentation and severity, synthesize your clinical assessment and rationale, frame the necessity of the specific treatment request clearly for a non-clinician medical director, cite relevant clinical guidelines, and ensure the letter is compelling and evidence-based. This approach lets you focus on comprehensive assessment while AI handles initial documentation.

Download (free)

This template is available as a printable PDF and editable DOCX file. Customize it to match your specialty and the types of requests you most frequently make, adjust for your patient population's common diagnoses, and use it as a standard format for all medical necessity letters.

[Download PDF]

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