How to use
Here is an example generator for a letter supporting a prescription for The Hayek for home use. This is only an example. Any letter, organized any way, can support your order.
Select Patient Letter
To use this template, please select the appropriate patient specific letter
Fill in Patient information
Fill in all the fields within the form and click on generate. The letter will appear below.
Copy Results to Letterhead
Copy and paste onto your letterhead and edit in your prefered text editing platform.
Letter of Medical Necessity for Respiratory Failure with PAP
Fill in all the fields within the form and click on generate.
Select the appropriate patient option:
Date:
Patient First Name:
Patient Last Name:
Date of Birth:
Primary Diagnosis:
Examples: Chronic Respiratory Failure
Comorbidities:
Examples: Pulmonary Hypertension, Hypoxemia, COPD
Symptoms:
Examples: hypercapnea , secretion retention secondary to pulmonary muscle weakness, atelectatic radiologic findings, and significant shortness of breath, loss of chest wall with poor mobility, secretion retention, loss of vocal volume with communication deficits, facial pressure sores from mask, and loss of quality of life
Diagnosis Results:
Examples: Severely elevated CO2 levels recorded as high as _ mmHg with pH of _, and O2 saturations on room air of _%. Radiologic findings indicate_. On most recent clinic visit Pulmonary Function Testing demonstrated severe deficits of VC _ /_ % of predicted, FEV1 _/_% of predicted, Negative Inspiratory Force of -_/_% of predicted.
Time of Use:
Example: 6 to 8 hours daily
Patient Goals:
Examples: providing rest to weak pulmonary muscles, provide increased reserves for activities of daily living, improved lung expansion, lung compliance, secretion clearance, improved pulmonary and organ system perfusion
Doctor's Name:
Letter of Medical Necessity for The Hayek Example
Here is an example generator for a letter supporting a prescription for usage of The Hayek at home. 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 in 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 The Hayek.
- Documentation of failed mask ventilation (if applicable)
- Why prescribing The Hayek (assertive tone recommended, not as a trial)
- Delineation or description of potentials for poor outcome without The Hayek
- Any tests (SUCH AS PULSE OX, ABGs, PFTs, CXRs, etc.)
The diagnoses for which usage of The Hayek is 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.
Letter of Medical Necessity
Here are examples of generators for a letter supporting a prescription for The Hayek for home use.