Sample Letter Of Medical Necessity Template Page 2

The following codes list the services and supplies provided:

92071RT

Fitting of CL for Ocular Surface Disease, OD

$________

92071LT

Fitting of CL for Ocular Surface Disease, OD.

$________

92072RT

Fitting of CL for keratoconus, OD

$________

92072LT

Fitting of CL for keratoconus, OS

$________

92313

Corneo-Scleral contact lens fitting

$________

V 2513

GP / EW, per lens

$________

V 2531

Scleral Gas Permeable, per lens

$_________

Information for keratoconus can be found on the Internet at , website for

the National Keratoconus Foundation. Your cooperation is greatly appreciated in

reviewing this case and obtaining lawful benefits for XXXXXXX. If you need any

further information, please feel free to contact our office.

Very sincerely yours,

James Smith, O.D.

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Parent category: Letters