Letter of Medical Necessity
A Letter of Medical Necessity (LMN) documents the clinical rationale for breast milk freeze-drying services as part of an exclusive human milk fortification strategy. This letter may be useful when submitting coverage requests to insurance providers or HSA/FSA administrators.
The template provided includes relevant ICD-10 codes, clinical rationale, evidence citations, and space for the prescribing provider to document the specific clinical circumstances of their patient.
Download the Template
The Letter of Medical Necessity template includes Milkify Medical letterhead and is available as a DOCX file that providers can customize for their patient's specific clinical circumstances.
Download DOCX TemplateExample Indications
The template covers caloric fortification of breast milk for patients with one or more of the following diagnoses:
Encouraged Enclosures
When submitting the Letter of Medical Necessity, the following supporting documents are encouraged:
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