Letter of Medical Necessity
A Letter of Medical Necessity may allow for Reimbursement for services with Diadem services. This MUST be requested by your Primary Care Physician. You are welcome to use this template as frequently as needed.
(Physician’s Letterhead)
(Date)
(Name of Pharmacy Director/Payer Contact)
(Contact Title)
(Name of Health Insurance Company)
(Address)
(City, State, ZIP Code)
RE: Coverage for (Service)
Patient: (Patient Name)
Date of Birth: (Date)
Diagnosis: (Diagnosis), (ICD-10-CM)
Group/Policy Number: (Number)
Policyholder: (Policyholder Name)
Dear (Pharmacy Director/Payer Contact Name):
I am writing on behalf of my patient, (Patient Name), to document the medical necessity to treat their (Diagnosis) with (Service).
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.
Summary of Patient’s Medical History and Diagnosis (Patient Name) is (Age) years old and was initially diagnosed with (Diagnosis) (ICD-10-CM) 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)
Rationale for Treatment (Include your clinical rationale and reasons for prescribing the (Service).
Rationale may include that you are seeking these alternatives because
-you believe that alternative treatments will improve your quality of life;
-you desire an alternative treatment that will not create dependency issues;
-you believe alternative treatments are a safer option with less option for side effects;
-you believe that alternative treatments are more flexible in meeting your health care needs;
-you are dissatisfied in some way with conventional treatment;
-you see alternative treatments as offering more personal autonomy and control over health care decisions;
-the alternatives are seen as more compatible with your values, worldview, or beliefs regarding the nature and meaning of health and illness.
In summary, (Service) is medically necessary and reasonable to treat (Patient Name’s) (Diagnosis), and I ask you to please consider coverage of (Service) on (Patient Name’s) behalf.
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,
(Prescribing Physician Name and Credentials) (NPI Number)
Enclosures: (List any Enclosures, such as: Prescribing Information, Medication Guide, and Clinical Notes and Records)
The National Institutes of Health’s Office of Alternative Medicine CLASSIFICATION:
Diadem Medicine offers the following services within the following categories:
Alternative Medicine
Chakra Healing with Ayurvedic interventions
Kinesiology combined with Chinese Medicine’s 5 Element Theory on Emotions
Meridian Therapy: Traditional Chinese Medicine
Bioelectromagnetic Therapies
Aura Healing
Chakra Healing
Consciousness Healing
Healy Frequency Therapy
Diet and Nutrition
Chakra Healing with Health Coaching
Herbal Medicine
Aromatherapy for Chakra Healing
Manual Healing Methods
Acupressure (this is patient driven, Diadem Medicine is not a hands-on provider.)
Mind-Body Interventions
Chakra Healing
Consciousness Healing
Dance / Movement Therapy
Guided Imagery
Meditation
Definitions
Emotional Clearing
Internationally Certified with the International Institute for Complementary Therapies, listed as The Spiral. The Spiral is the program. Emotional Clearing is the modality.
includes: Acupressure, Chakra Healing, Consciousness Healing, Meridian Therapy: Traditional Chinese Medicine, Kinesiology, and may include others listed above.
Healy Frequency Therapy
The Healy is cleared by the FDA as Class 2 medical equipment for relief of acute, chronic, and arthritis pain, as well as for muscle soreness.
In Europe, Healy supports treatment of pain in chronic pain, fibromyalgia, skeletal pain, and migraine, as well as for the supportive treatment of mental illnesses such as depression, anxiety, and related sleep disorders.
