Letter of Medical Necessity (LMN) Template

Copy and paste the text below into a document, or print this page to bring to your next doctor's appointment. Clinical Protocol information (including ICD-10 Codes) can be found on the HSA & FSA Acceptance page.

Date: _______________

Patient Name: ____________________________________ Date of Birth: _____________

Insurance Policy ID: ________________________ Group #: __________________

To Whom It May Concern,

I am currently treating the patient named above for [Primary Condition Name], ICD-10 Code: _______________ (e.g., M79.7 for Fibromyalgia, F41.1 for Generalized Anxiety Disorder, or G47.00 for Insomnia).

As part of their comprehensive treatment plan, I am prescribing Reiki therapy to assist with [Specific Clinical Symptom/Goal, e.g., chronic pain management, autonomic nervous system regulation, stress reduction].

The patient has previously attempted standard care, including [Prior Treatments/Medications Tried, e.g., physical therapy, OTC analgesics, sleep hygiene protocols], which have yielded incomplete relief or undesirable side effects.

I recommend [Frequency, e.g., weekly, monthly] sessions for a duration of [Timeframe, e.g., 8 weeks, 3 months] under CPT Code / CPT Service Description: 97139 / Unlisted Therapeutic Procedure - Reiki Therapy.

This therapy is medically necessary to support symptom relief, improve functional outcomes, and manage the patient's underlying condition.

Provider Name & Credentials: ____________________________________________

Practice Name / Address: ________________________________________________

NPI #: ___________________ Tax ID (TIN): ___________________

Provider Signature: ___________________________________ Date: ___________