Last night, I had dinner with my mom. After dinner, I showed her the letter of medical necessity that my PT wrote for me to receive a new walker. In many cases, a letter of medical necessity is the first step in receiving medical equipment or treatment.
In the letter, my PT described my diagnosis of Cerebral Palsy and how it affects me. He also included some of my medical history, such as surgeries. The letter also provides information about the chronic pain I experience in my hip adductors.
Adductors are any muscles that pull a body part toward the axis of an extremity or toward the body’s median line. The pectineus, adductor longus, gracilis, adductor brevis, and adductor magnus are the primary hip adductors.
A letter of medical necessity is written by a healthcare professional requesting coverage for a specific test, treatment, or equipment because it is the one that is right for you. The letter frequently includes pertinent patient information such as medical needs, daily living needs, and treatment duration.
We also talked about my ability to complete ADLs. In addition, we talked about my level of function according to the Gross Motor Function Classification System, among other things.
The Gross Motor Function Classification System (GMFCS) is a five-level classification system used to describe the gross motor function of people with cerebral palsy. It is based on self-initiated movement, focusing on sitting, walking, and mobility.
We also talked about different equipment that wouldn’t meet my needs. This equipment included a cane, a two-wheeled walker, and a motorized scooter. Letters of medical necessity are more helpful to the insurance company if they are as specific as possible.
While I am grateful that my PT is willing to help me get what I need, it is frustrating to know that my insurance likely won’t cover it immediately. However, because my equipment costs thousands of dollars, it is untenable for me to pay for it out of pocket.
The people who make these decisions have never met or spoken to me. I am more than a letter of medical necessity or a diagnosis, but that is how they see me. It is impossible for a letter to describe everything about my life. Sometimes, I wish the health insurance company could spend a day in my shoes.
Navigating bureaucratic systems is a long, emotional process that can take years. Disabled people often have to fight for things that improve their daily lives. I am tired of having to fight for things that I need.
Sources:
“Adductor Muscle.” Encyclopædia Britannica, Encyclopædia Britannica, inc., 13 Sept. 2011, http://www.britannica.com/science/adductor-muscle.
‘Chapter 9 – Structure and Function of the Hip’. Essentials of Kinesiology for the Physical Therapist Assistant (Third Edition), edited by Paul Jackson Mansfield and Donald A. Neumann, Mosby, 2019, pp. 233–277, https://doi.org10.1016/B978-0-323-54498-6.00009-6.
Richards, Carol L., and Francine Malouin. ‘Chapter 18 – Cerebral Palsy: Definition, Assessment and Rehabilitation’. Handbook of Clinical Neurology, edited by Olivier Dulac et al., vol. 111, Elsevier, 2013, pp. 183–195, https://doi.org10.1016/B978-0-444-52891-9.00018-X.
Sliney Jr., James. “Your Best Defense: The Letter of Medical Necessity.” Patients Rising, Patients Rising, 18 May 2022, http://www.patientsrising.org/letter-of-medical-necessity/.
You go girl!