2025 Letter of Medical Necessity for Emotional Clearing
A Letter of Medical Necessity may allow for Reimbursement for EMOTIONAL CLEARING services with Diadem Medicine.
The LMN is completed by your Primary Care Physician.
You are welcome to use this template as frequently as needed. updated January 1, 2025
Emotional Clearing
Emotional Clearing is Internationally Certified with the International Institute for Complementary Therapies, listed as The Spiral. The Spiral is the program. Emotional Clearing is the modality.
includes: Kinesiology, Traditional Chinese Medicine, Acupressure, and Breathwork.
(From Primary Doctor)
Physician’s Letterhead is preferred
Must include:
Address, City, State, Zip
Phone
Website (if applicable)
Date
(Recipient)
Name of Company/Payer Contact
Must include:
POC/Contact Office Name
Address, City, State, Zip
Phone
Website (if applicable)
RE: Letter of Medical Necessity for Alternative Treatment / Complementary and Alternative Medicine (CAM)
Patient Name
Date of Birth
Medical Condition or Diagnosis:
Must include: Diagnosis with ICD-10-CM Codes (if applicable)
Dear FSA, HSA, HRA, Insurance Company Name,
I am writing on behalf of my patient, Name, to document the Medical Necessity to treat their (Diagnosis with ICD codes_____________________________) with a Complementary and Alternative Medicine (CAM) approach.
My patient is seeking Emotional Clearing (EC) as an alternative and/or complement to traditional mental health therapy with Diadem Medicine.
Emotional Clearing is the modality from The Spiral Program, an approved modality with the International Institute for Complementary Therapies (IICT), offering an Alternative Treatment beyond the program.
Diana M. Pine, Eastern Therapies Practitioner at Diadem Medicine, is a Certified Spiral Practitioner, specifically trained in the Emotional Clearing modality.
This letter serves to document my patient’s medical history and diagnosis and to summarize my treatment rationale. Please refer to the (List any Enclosures) enclosed with this letter.
1. Summary of Patient’s Medical History and Diagnosis
(Patient Name_____) is (Age_____) years old and was initially diagnosed with (Diagnosis with ICD-10 _____) on (Date_____).
(Patient Name_____) has been in my care since (Date_____). (Provide a discussion of the patient’s clinical history, current symptoms and condition, any potential contraindications, and any relevant laboratory test results, highlighting the factors leading you to recommend use of the (Service)
2. Rationale for Treatment
(Include your clinical rationale and reasons for prescribing the (Service).
Rationale may include that you are seeking these alternatives because:
· NAME believes that alternative treatments will improve their quality of life;
· NAME desires an alternative treatment that will not create dependency issues;
· NAME believes alternative treatments are a safer option with less option for side effects;
· NAME believes that alternative treatments are more flexible in meeting their health care needs;
· NAME is dissatisfied in some way with conventional treatment;
· NAME sees alternative treatments as offering more personal autonomy and control over health care decisions;
· NAME sees CAM as more compatible with your values, worldview, or beliefs regarding the nature and meaning of health and illness.
In summary, this CAM option is medically necessary and reasonable to treat (Patient Name’s_____) (Diagnosis_____), and I ask you to please consider coverage of:
Emotional Clearing (EC) as an alternative and/or complement to traditional mental health therapy on (Patient’s) behalf.
3. Recommended Treatment
Describe Recommended Treatment
include the specific service/item and frequency and dosage.
Duration of Treatment (EC Sessions are most effective when used in 8 and 12 session treatment plans.)
To support the clients preference for CAM, please indicate “lifetime” as the duration of treatment.
FYI For the PCP (include in the LMN as necessary)
Emotional Clearing (EC) is a combination of Applied Kinesiology, Traditional Chinese Medicine, Vedic Medicine, and Breathwork.
Emotional Clearing is generally offered for the release of conscious and subconscious emotional blocks, emotional imbalance, energetic imbalance, and mental disharmony to improve health and accelerate healing.
EC offers NCCIH compliant CAM Psychological and Physical approaches for IH, collectively the Mind and Body Practices. (for more information: https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name).
In session, EC may include any or all of the following CAM approaches:
· Psychological (eg: mindfulness, spiritual practices),
· Physical, practitioner-guided/patient-implemented, (eg: somatic movement, acupressure),
· combinations of Psychological and Physical approaches (eg: meditation, breathing and relaxation techniques, art, music, dance, movement, education, and energy therapy)
Other approaches may be used for at home, integration practices include reiki.
EC is considered a Complementary and/or Alternative Medicine (CAM) depending on its use.
· EC is Complementary when used together with conventional mental health/psychotherapy services for a specific mental health diagnosis.
· EC is Alternative when it is used in place of conventional medicine.
Integrative Health (IH) brings complementary and conventional approaches together in a coordinated way. A variety of combinations support IH to treat the whole person rather than, for example, one organ system. EC supports IH when used as a complementary approach as it combines the multimodal interventions of Kinesiology, Traditional Chinese Medicine, Breathwork, and traditional (shamanic) healers even when not being used together with conventional medicine. EC also supports the IH approaches of Vedic Medicine, more specifically as a healing practice that uses the concept of, as well as the psychology of, the chakras to balance energy in the body, which has a direct influence on a person’s health and well-being. EC supports physical, energetic, emotional, mental, and spiritual health.
Emotional Clearing services may be offered throughout the lifetime of the patient to clear patterns and sustain healing goals. No more than one EC session is recommended per week.
Please refer to the enclosed supporting documents for further details, and do not hesitate to call me at (Phone Number) if you have any questions or if you require additional information.
Thank you for your attention to this matter.
Sincerely,
Signature
Prescribing Physician Name and Credentials
NPI Number
Enclosures:
(List any Enclosures, such as: Prescribing Information, Medication Guide, and Clinical Notes and Records)
—————
**It may also be helpful to include these brochures:
Physician Referral Guide for CAM with Diadem Medicine
Diadem Medicine Services Overview
