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Sample Letter of Medical Necessity

PATIENT NAME: Baby Sally
DOB: 4-30-09
PHYSICIAN: (your doctor)
EQUIPMENT REQUIRED: RES-Q WEDGE /ORTHOPEDIC DEVICE

To Whom It May Concern:

I am the primary care physician for the above-referenced child who has been diagnosed with ……. Due to the severity of her reflux, she has been choking when lying down in her crib. She is unable to achieve deep sleep states and awakens throughout the night frequently, and she is chronically congested. The patient is unable to stay elevated safely on her current crib mattress and she is at high risk for aspiration.

I consider it medically necessary for this patient to be equipped with a RES-Q INFANT WEDGE ORTHOPEDIC DEVICE in order to facilitate optimum functional positioning. This will be required for a minimum of 3 months. The RES-Q Wedge and sling is necessary for Baby Sally in order to extend restorative sleep periods, improve systemic functions such as respiration and digestion, address musculoskeletal alignment, provide 30 degrees of elevation safely, and may eliminate the need for reflux medication.

Orthopedic Product Features:

The patented design will facilitate proper musculoskeletal alignment for the cervical and lumbar spine while providing good shoulder protraction and hip placement. The wedge is reversible. The “nest” side promotes good head molding for infants who sleep in a supine position. The curvilinear side is for prone resting. The RES-Q Device comes with an adjustable sling that may be moved up or down the incline of the wedge to customize the infant’s resting position.

Please do not hesitate to contact …….., Triage Nurse, at (123) 456-7890 if you have any questions regarding this equipment. Thank you for your understanding and attention.

Sincerely,

(Your doctor)