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Sample Letter of Medical Necessity


    (TODAY’S DATE)

    I am Dr. Robert Spalding, a podiatrist in Chattanooga, Tennessee. I have seen (Name of Patient) (DOB: //__) on a medical visit with his wife in my office on (Date of Visit). He presented with Type II Diabetes and peripheral neuropathy as his chief complaint. He controls his diabetes with weekly injections of Ozempic 2mg and Tresiba 66 units daily at night. He reports no recent hospitalizations or surgeries in the past 5 years but did have 5 coronary bypasses on 3/17/2017 that left him with rib pain from bending over to put on his socks. He takes a beta-blocker and statin to control hypertension and hyperlipidemia.

    He stated he had difficulty reaching his toes to perform routine foot care, had discomfort with burning in his toes, and mentioned he was taking Amitriptyline 25mg for intermittent neuropathic pain with partial relief. He also complained of painful heel fissures from dry skin due to his diabetes, and he got relief from applying urea to his heels when he was able to reach his feet.

    He mentioned that when he had foot pain, he got additional relief with applying certain OTC topical creams like Voltaren and CBD products but had trouble applying them. He had adequate DP/PT pulses, diminished vibratory sense, and dry skin on his heels with some fissuring. He said he had no luck with other extension devices to apply creams, and his wife was unable to apply creams for him due to pain in her hands from Parkinson’s disease and her back and neck pain. I suggested changing from Amitriptyline to Neurontin, exercising his toes when sitting, and trying a prescription compounded cream for his peripheral neuropathy.

    I am aware of a new product called Foot Jelly that has several advantages for helping patients with providing physical therapy for neuropathy and restricted lower extremity access, like (Patient’s Name). I certify a letter of medical necessity for this device for this patient to assist with his topical cream application to manage his dry skin condition from diabetes and pain control for his neuropathic pain. Foot Jelly also aids in exercising his toes to improve circulation and indirectly improves his balance by increasing the intrinsic muscle activity of his feet.

    In summary, Foot Jelly is medically necessary to effectively address my patient’s health condition and improve their overall well-being for routine foot care. Please consider coverage or reimbursement for the mentioned Foot Jelly on behalf of (Name of Patient).

    If you have any questions, you can reach me at [Phone Number] or via email at [Email Address].

    Thank you for your time and consideration.

    Sincerely,

    (Name of Doctor or Health Professional), DPM, MD, DO, NP