Letter of Medical Necessity for BCV Example

Here is an example generator for a letter supporting a prescription for a Hayek Biphasic Cuirass Ventilator for home use. It has been used successfully as a template by physicians to expedite insurance authorization and secure this therapy for their patients. This is only an example. Any letter organized any way can support your order.

It is recommended that any letter submitted, if possible, include the following information:

• Patient, clinic/facility and prescriber identifying information
• Patient condition & diagnoses relative to the prescription
• Recent reoccurrence of admission, emergent or unscheduled clinic visits due to symptoms treatable with BCV.
• Documentation of failed mask ventilation (if applicable)
• Why prescribing BCV (assertive tone recommended, not as a trial)
• Delineation or description of potentials for poor outcome without BCV
• Any tests (SUCH AS PULSE OX, ABGs, PFTs, CXRs, etc.)

The diagnoses for which BCV are ordered are the same as other types of respiratory support. Documentation of need of ventilatory support for respiratory insufficiency are those the payors find most acceptable. The data elements that best support the prescription are those that demonstrate disease severity including need for routine support. Secretion Clearance is an available option and it should be prescribed with support settings such as Continuous Negative or Control.

Documentation of previous failed attempts or poor compliance with other chest physiotherapy treatments, mask ventilation, PAP device or other forms of support will help build a strong case for approval.

Thank you for your prescription for BCV. Please do not hesitate to reach out to your regional Hayek Clinical Specialist or contact us at 855-243-8228.