Insurance Letter of Medical Necessity

Medical Necessity Information

Health insurance organizations in the U.S. or other third-party payers may not routinely cover some treatments for vitiligo and/or they may require documentation of medical necessity when particular treatments are prescribed before deciding to pay for these treatments. Healthcare providers can adapt the following letter of medical necessity to provide documentation of your need for a particular therapy.

Sample Letter of Medical Necessity for Vitiligo Treatment

[Insurer name]
Attn: [Name of individual]

re: [Patient name]
[Policy number]

Dear [Insurer name]:

I am writing on behalf of [Patient name] to document the medical necessity of [insert treatment option here] for the treatment of vitiligo. This letter provides information about the patient’s medical history and diagnosis and a statement summarizing my treatment rationale.

Vitiligo, or the depigmentation of skin and hair, is a medical condition that can have a devastating effect on a patient’s quality of life, causing physical discomfort, secondary skin problems, social/emotional sequelae such as anxiety, and depression, and occupational and relationship challenges. This has certainly been true for [Patient name], who has been impacted by vitiligo for [insert duration of symptoms here].
Specifically, [he or she] has had difficulties with [insert quality-of-life, social/emotional, and/or career/daily living problems here].

[Discuss patient’s diagnosis, treatment history, and degree of illness]

[Insert patient’s name] has tried the aforementioned therapies thus far without success and I, therefore, recommend [insert treatment option here] as the next logical choice for treating [his or her] vitiligo.

In light of this clinical information, and this patient’s condition, [insert treatment option here] is medically necessary and warrants coverage. Please contact me at [(000) 000-
0000] if you require additional information.

[Physician’s name]

Click Here to Download the Medical Necessity Letter (MS Word)

Research Support

Selected Vitiligo Research References

  1. Elbuluk N, Ezzedine K. Quality of Life, Burden of Disease, Co-morbidities, and Systemic Effects in Vitiligo Patients. Dermatol Clin. 2017;35(2):117-128. doi:10.1016/j.det.2016.11.002
  2. Morales-Sánchez MA, Vargas-Salinas M, Peralta-Pedrero ML, Olguín-García MG, Jurado-Santa Cruz F. Impact of Vitiligo on Quality of Life. Impacto del vitíligo en la calidad de vida. Actas Dermosifiliogr. 2017;108(7):637-642. doi:10.1016/
  3. Kota RS, Vora RV, Varma JR, Kota SK, Patel TM, Ganjiwale J. Study on Assessment of Quality of Life and Depression in Patients of Vitiligo. Indian Dermatol Online J. 2019;10(2):153-157. doi:10.4103/idoj.IDOJ_14_18
  4. Yucel D, Sener S, Turkmen D, Altunisik N, Sarac G, Cumurcu HB. Evaluation of the Dermatological Life Quality Index, sexual dysfunction and other psychiatric diseases in patients diagnosed with vitiligo with and without genital involvement [published online ahead of print, 2020 Nov 15]. Clin Exp Dermatol. 2020;10.1111/ced.14511. doi:10.1111/ced.14511
  5. Bae JM, Lee SC, Kim TH, et al. Factors affecting quality of life in patients with vitiligo: a nationwide study. Br J Dermatol. 2018;178(1):238-244. doi:10.1111/bjd.15560
  6. Nicolaidou E, Mastraftsi S, Tzanetakou V, Rigopoulos D. Childhood Vitiligo. Am J Clin Dermatol. 2019;20(4):515-526. doi:10.1007/s40257-019-00430-0
  7. Ezzedine K, Silverberg N. A Practical Approach to the Diagnosis and Treatment of Vitiligo in Children. Pediatrics. 2016;138(1):e20154126. doi:10.1542/peds.2015-4126

Text from this page is adapted from the International Hyperhidrosis Society