Letter of Medical Necessity (Drug)
Builds a letter of medical necessity for a drug.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Drug, dose and schedule
- drug 40 mg every 2 weeks
- Diagnosis with ICD-10-CM code
- Rheumatoid arthritis, M06.9
- Date of diagnosis
- 2024-03
- The use is an FDA-approved indication
- Yes
- Patient name
- Pat Doe
- Member ID
- X123
- Plan name
- Acme Health
- Prior therapies, one per line
- methotrexate, 2025-01 to 2025-06, inadequate response
- Payer criteria and where the evidence is, one per line
- 1. Diagnosis of RA: met (progress note 2026-08-14)
- Prescriber name, credentials and NPI
- Dr. Lee, MD, NPI 1234567890
- Letter date
- 2026-09-20
Result: Letter of medical necessity for drug 40 mg every 2 weeks. 1 blank left to fill before sending.
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Drug, dose and schedule
- Diagnosis with ICD-10-CM code
- Date of diagnosis
- The use is an FDA-approved indication
- Patient name
- Member ID
- Plan name
- Prior therapies, one per line
- Payer criteria and where the evidence is, one per line
- Prescriber name, credentials and NPI
- Letter date (YYYY-MM-DD; blank for today)
How this is calculated
Citation
Assembles the reader's diagnosis, drug, prior therapies and the payer's own criteria with their evidence; a Medicare Advantage plan's internal coverage criteria must be publicly accessible (42 CFR 422.101(b)(6)(ii)). The clinical rationale is the prescriber's. Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.