Sometimes, orthodontic work is more than just about a perfect smile. It can be a medical necessity. This is when a patient needs braces or other treatments to fix problems with their teeth or jaw. If your doctor recommends orthodontia for medical reasons, you might need help from your insurance company.
That’s where a specific letter comes in. It’s a formal request to your medical insurance. The goal is to get them to cover the costs of your medically necessary orthodontic treatment. Writing this letter can seem daunting.
We’ve got you covered. We’ll share sample letters you can adapt. These examples will guide you. You can easily create your own letter. Let’s make this process simpler for you.
Sample Letter To Medical Insurance Company Requesting Medically Necessary Orthodontia
[Your Name]
[Your Address]
[Your City, State, Zip Code]
[Your Phone Number]
[Your Email Address]
[Date]
[Insurance Company Name]
[Insurance Company Address]
[Insurance Company City, State, Zip Code]
**Subject: Request for Pre-Authorization of Medically Necessary Orthodontia – [Patient Name], Policy Number: [Your Policy Number]**
Dear [Claims Department/Specific Contact Person, if known],
This letter is to request pre-authorization for orthodontic treatment for my [son/daughter], [Patient Name], whose date of birth is [Patient Date of Birth] and who is covered under my medical insurance policy, number [Your Policy Number].
[Patient Name] has been evaluated by a certified orthodontist, Dr. [Orthodontist’s Name], at [Orthodontist’s Office Name], located at [Orthodontist’s Address]. Dr. [Orthodontist’s Name] has determined that [he/she] requires orthodontic treatment to correct a severe malocclusion that is causing significant functional problems.
Specifically, [Patient Name] suffers from [Clearly and concisely describe the medical problem, e.g., a severe overbite, open bite, crossbite, impacted teeth, temporomandibular joint (TMJ) dysfunction]. This condition is causing [Explain the consequences of the condition, e.g., difficulty chewing, speech impediments, pain, increased risk of dental trauma, difficulty breathing].
Dr. [Orthodontist’s Name] has indicated that orthodontic treatment is medically necessary to alleviate these problems and improve [Patient Name]’s overall health and well-being. Attached you will find Dr. [Orthodontist’s Name]’s report, including diagnostic records such as X-rays and photographs, which further detail the medical necessity of this treatment.
We understand that orthodontic coverage may be limited, but we believe that [Patient Name]’s case warrants an exception due to the significant medical issues involved. We are confident that the attached documentation clearly demonstrates the medical necessity of this treatment.
We kindly request that you review this information and approve pre-authorization for [Patient Name]’s orthodontic treatment. Please contact me at [Your Phone Number] or [Your Email Address] if you require any further information. We look forward to your prompt response.
Sincerely,
[Your Signature]
[Your Typed Name]
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How to Write Letter To Medical Insurance Company Requesting Medically Necessary Orthodontia
Subject Line: A Concise Declaration
The subject line should be trenchant and immediately convey the letter’s purpose. Avoid vagueness. Instead, be direct. For example:
- “Prior Authorization Request for Medically Necessary Orthodontic Treatment – [Patient Name], [Policy Number]”
- “Appeal for Orthodontic Treatment – Medical Necessity – [Patient Name], [Policy Number]”
Salutation: Setting a Formal Tone
Address your insurance company respectfully. If you know a specific contact person, use their name. If not, a formal greeting suffices. Consider these options:
- “Dear [Insurance Company Name] Claims Department,”
- “Dear [Specific Contact Person],”
Maintain a professional demeanor from the onset.
Introduction: Establishing Medical Imperative
The opening paragraph should immediately articulate the purpose of the letter and underscore the medical necessity of the orthodontic treatment. Don’t equivocate. Clearly state:
- The patient’s name, date of birth, and policy number.
- A concise statement that you are requesting pre-authorization or appealing a denial for medically necessary orthodontic treatment.
- A brief overview of the patient’s malocclusion and its ramifications on their health.
For instance: “I am writing to request pre-authorization/appeal the denial for medically necessary orthodontic treatment for my [son/daughter/self], [Patient Name], born on [Date of Birth], policy number [Policy Number]. This treatment is crucial to correct a severe malocclusion that is adversely affecting [his/her/my] oral health and overall well-being.”
Body Paragraphs: Substantiating the Claim
This section is the crux of your argument. Provide detailed information and compelling evidence supporting the medical necessity. Include:
- Diagnosis: Explicitly state the patient’s orthodontic diagnosis (e.g., Class II malocclusion, severe overbite, crossbite).
- Clinical Ramifications: Detail how the malocclusion impairs the patient’s functionality. Examples include difficulty chewing (mastication), speech impediments, temporomandibular joint (TMJ) dysfunction, increased risk of dental trauma or decay, and breathing problems.
- Orthodontist’s Assessment: Reference the orthodontist’s evaluation, treatment plan, and prognosis. Include supporting documentation such as X-rays, photographs, and written reports. Emphasize the orthodontist’s professional opinion on the necessity of the treatment.
- Impact on Quality of Life: Explain how the condition affects the patient’s daily life, including psychological and social aspects.
- Previous Treatments (if any): Detail any previous treatments attempted and their outcomes.
Supporting Documentation: Bolstering Your Case
Refer to all enclosed documents, signaling their pertinence. Ensure clarity in your allusions. Examples of supporting documents include:
- Orthodontist’s comprehensive evaluation and treatment plan
- Cephalometric radiographs and panoramic X-rays
- Clinical photographs
- Letters of medical necessity from the orthodontist or other relevant healthcare providers
- Previous claim denials (if applicable)
- Any relevant medical records
Call to Action: A Decisive Conclusion
In the concluding paragraph, reiterate your request and express your expectation for a favorable response. Be proactive and suggest next steps. For example:
- Reiterate your request for pre-authorization or appeal the denial.
- Offer to provide additional information or documentation.
- Request a written response outlining the insurance company’s decision.
- Provide your contact information for easy communication.
Example: “I urge you to reconsider this request for medically necessary orthodontic treatment. Please find enclosed all supporting documentation as outlined above. I am available to provide any further information needed. Kindly forward a written response detailing your decision to [Your Address] or [Your Email Address]. I can also be reached by phone at [Your Phone Number].”
Closing: Formal Valediction
End the letter with a professional and respectful closing.
- “Sincerely,”
- “Respectfully,”
Followed by your typed name and signature.
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Frequently Asked Questions: Medically Necessary Orthodontia
Navigating medical insurance for orthodontia can be complex. This FAQ addresses common questions regarding requesting coverage for medically necessary orthodontic treatment.
What constitutes “medically necessary” orthodontia?
Medically necessary orthodontia typically involves conditions that impact oral function, such as difficulty chewing, speaking, or breathing, and are not purely cosmetic concerns.
What documentation should I include with my request letter?
Include a detailed letter from your orthodontist explaining the medical necessity, diagnostic records (X-rays, photos), and any supporting documentation from other medical professionals.
How do I address the insurance company in my letter?
Address the letter to the “Medical Director” or “Appeals Department” of your insurance company. You can find the specific address on your insurance card or policy documents.
What if my initial request is denied?
If your initial request is denied, you have the right to appeal the decision. Follow the appeals process outlined by your insurance company, providing additional supporting documentation.
How long does it typically take to receive a response?
The response time varies by insurance company. Check your policy documents for specific timelines, but typically, you can expect a response within 30-60 days.