Medical Necessity Letter Example
[ Date ]
To Whom It May Concern:
_______ had been diagnosed as having Ménière's disease, a disorder characterized by recurrent spells of vertigo in association with unilateral hearing loss. The patient was initially treated medically, but the symptoms have worsened to the point where it adversely affects his/her mobility and lifestyle.
Since this patient has failed medical treatment, along with a low-sodium diet, other treatment options have been entertained. The surgical options include an endolymphatic mastoid shunt, a selective vestibular nerve section and transtympanic gentamycin injections. All of these options are invasive and do carry a significant risk of hearing loss and possibly loss of balance.
A less invasive option is now available through the use of the Meniett® Low Pressure Pulse Generator (HCPCS code E2120). The Meniett device is a pressure-delivery system, that delivers micro-pressure pulses into the ear canal, which are subsequently transmitted through a tympanostomy tube into the middle ear space. The pressure is transmitted through the round window into the inner ear where it is believed to displace the excess fluid within the inner ear and in so doing, controls the vertigo symptoms of Ménière's disease in 70-90% of patients in clinical studies.
I believe that this device would potentially control the patient's vertigo spells at a reduced risk and a reduced cost and would be in
the patient's best interests. The patient would like to proceed with obtaining the Meniett device to control his/her vertigo.
Please consider coverage of the Meniett device for ______ in lieu of the more invasive and potentially risky surgical options mentioned above. If additional information would prove helpful, please do not hesitate to contact me.
Sincerely,
[PHYSICIAN NAME]
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