Letter of medical necessity

For when the laboratory doesn't supply a letter. Replace each bracketed part from the chart, cite the guideline that covers this test and indication (for hereditary cancer, NCCN; otherwise the relevant society statement or the GeneReviews chapter), and don't cite a guideline you haven't read. Send it through your usual secure channel.

[Date]

To: [Insurer], Utilization Review or Medical Director
Re: [Patient name], date of birth [date], member ID [ID]
Test: [test name], [laboratory], CPT [codes]

I am writing to request coverage for [test name] for my patient, [patient name].

Clinical indication. [Diagnosis or suspected diagnosis, with ICD-10 codes.] [Two to four sentences: the presentation, the relevant findings, and the prior workup with its results.]

Family history. [Relevant relatives and their diagnoses. Pedigree attached if available.]

Why testing now. [What makes the diagnosis likely, and why earlier testing did not answer the question.]

How the result will change management. [Specific actions that depend on the result: treatment, surveillance, tests avoided, and cascade testing of relatives.]

Supporting guideline. [guideline or society statement, with its citation and the section that applies.]

The laboratory's price for this test is [amount]. I am happy to discuss this request with your medical director at [phone].

Sincerely,
[Name and credentials]
[Practice, address]
NPI [number], [phone], [secure fax or address]

Colorado Care Network. Letter of medical necessity. Version 2026-10-30.