Letter of Medical Necessity Sample: What a Real One Says
A full sample letter of medical necessity, explained section by section, plus why blank templates get denied and how specific the item must be for your plan.
6 minute read
Short answer
A letter of medical necessity is about one page: a dated header, the patient's name, the diagnosis, the specific item being recommended and why it treats that diagnosis, how long the patient needs it, and the clinician's credentials and signature. Below is a full sample written for a walking pad, with each part explained. A template you fill in and sign yourself does not count; a licensed clinician has to evaluate you and sign it. If you want one written for you, Burst does it online for $35, reviewed and signed by a licensed clinician, usually the same day.
What does a letter of medical necessity look like?
Here is a complete sample. The patient, clinician, and clinic are made up; the structure is what plan administrators expect to see.
Northside Family Medicine
1420 Oak Street, Suite 200, Portland, OR 97205
Date: September 3, 2026
Re: Letter of Medical Necessity for Maria Alvarez, DOB 04/12/1981
To whom it may concern:
I am the treating clinician for Maria Alvarez. Ms. Alvarez has been diagnosed with essential hypertension (ICD-10 I10) and obesity with a BMI of 33 (ICD-10 E66.9). Her blood pressure at her most recent visit was 146/92 despite medication.
As part of her treatment plan, I am recommending a home walking treadmill (under-desk walking pad) so that she can complete 30 to 45 minutes of moderate walking on most days. Regular aerobic activity is a first-line treatment for both of her conditions and is expected to lower her blood pressure and support weight reduction. Ms. Alvarez works from home and has reported that a home device is the only realistic way for her to reach this activity target.
This recommendation is for the treatment of the diagnosed conditions above, not for general fitness or convenience. The device is medically necessary for a period of 12 months from the date of this letter, at which point I will re-evaluate.
Please contact my office with any questions.
Sincerely,
Daniel Okafor, DO
Oregon medical license 45XXX
Northside Family Medicine, (503) 555-0142
What each part of the letter does
Every section above answers a question a claims reviewer is required to ask. Leave one out and the claim comes back with a request for more information.
Section | What it has to contain | Why the plan cares |
|---|---|---|
Header and date | Clinic name, address, phone, and the date signed | The date starts the letter's 12-month window, and the clinic details let the plan verify it |
Patient | Full name and date of birth | Must match the account holder or a covered dependent on the plan |
Diagnosis | A named condition, ideally with the ICD-10 code | This is the line that separates a medical expense from a personal one |
Recommendation | The specific item, and one or two sentences on how it treats the diagnosis | The item on the letter has to match the item on the receipt |
Duration | How long the item is needed, usually 12 months | Tells the plan which purchases inside the window the letter covers |
Clinician | Name, credentials, license number or state, signature | Only a licensed clinician's judgment counts; the plan may check the license |
Why a blank template is not a letter of medical necessity
A template is a form with empty fields. The letter is the clinician's judgment about you, written down and signed. Most administrators publish their own blank form (HealthEquity, Optum, and FSAFEDS all do) and every one of them has a signature line for a licensed provider, because the form has no value until a clinician who evaluated you signs it. Filling in your own name, diagnosis, and item and sending it in gets denied.
Where a template is useful: bringing one to your own doctor so the office does not have to guess what your plan wants. Many primary care offices have never been asked for one.
Why do plans reject letters of medical necessity?
Almost always because the letter is vague on one of three points.
No diagnosis. "Recommended for the patient's health and wellbeing" describes everyone. The reviewer needs a condition.
Item does not match the receipt. The letter says "exercise equipment," the receipt says "WalkingPad C2, $399." Some plans accept that. Many do not. The sample above says "home walking treadmill (under-desk walking pad)" so the match is obvious.
Wrong dates. The letter is dated after the purchase, or the purchase falls outside the 12-month window. Plans check.
A fourth, quieter reason: the letter reads like it was written for anyone. Reviewers see hundreds of these. A sentence like "Ms. Alvarez works from home and has reported that a home device is the only realistic way for her to reach this activity target" is what a real clinical note sounds like, and it is the kind of detail that gets a letter through on the first pass.
How to get a letter for your purchase
Open app.getburst.com/request-lmn and tell us what you plan to buy and what health condition it is for. The form takes under 2 minutes.
A licensed clinician reviews your answers. If a letter is appropriate, you get a signed, dated PDF by email, usually the same day, written in the format above with the item named specifically. If the clinician decides a letter is not appropriate, the $35 is refunded automatically.
Buy the item at any store, with any card. Then send Burst the receipt, and Burst files the reimbursement claim with your plan. The administrator then pays you from your FSA, HSA, or HRA, and a denied claim gets the $35 back to you.
Frequently asked questions
Can I write my own letter of medical necessity?
No. You can draft one for your clinician to review, but the signature, credentials, and clinical judgment have to be theirs. Plans do not accept self-written letters.
Does the letter need a diagnosis code?
Most plans do not require an ICD-10 code, but a named diagnosis is required, and the code removes any ambiguity. Ask your clinician to include it.
How specific does the item need to be?
Specific enough that the receipt obviously matches. Brand and model are not required; the type of item is. "Home walking treadmill" covers a WalkingPad, a UREVO, or a LifeSpan. "Fitness equipment" may not.
Does a letter of medical necessity expire?
Yes. Nearly every plan treats a letter as valid for 12 months from the signing date, and some administrators' forms say so on the form itself. The letter supports purchases of that item inside the window; after that you need a new one.
Does it have to be on letterhead?
Not strictly, but it needs the clinic or clinician's contact information and license details so the plan can verify it. Letterhead is the easiest way to include that.
Related: What is a letter of medical necessity?, Letter of medical necessity vs. prescription, and How to file your letter for reimbursement.
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