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LETTER OF MEDICAL NECESSITY
Date

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Date
To Whom It May Concern / Claims Administrator:

I am writing on behalf of my patient to document the medical necessity of specialized Neuro-Somatic Kinesiology, Visceral-Somatic Recovery, and Structural Manual Therapy for the treatment of their diagnosed medical condition(s).
Patient Name
First Name Last Name DOB Insurance Member/ID Group Number(if applicable)
Patient Clinical Diagnosis:
The patient presents with the following chronic or acute conditions

Other
Treatment Plan & Justification:

The patient requires a structured, multi-modality clinical approach to address deep-seated fascial restrictions, somatic trauma retention, and neural compensation loops. Standard conservative therapies have yielded insufficient long-term relief.

I have prescribed a 90-Day Neuro-Somatic Recovery Program consisting of targeted manual craniosacral decompression, visceral mobilization, and functional movement re-education. This clinical intervention is required to down-regulate sympathetic nervous system hyper-arousal, increase vagal tone, and restore structural alignment to alleviate debilitating pain.

Prescribed Frequency & Duration:

Frequency: 1 to 2 therapeutic sessions per week during acute phases, tapering down to bi-weekly maintenance.

Duration: 90 Days (Totaling approximately 10 to 12 sessions).
In my professional medical opinion, this treatment is not for general wellness or cosmetic purposes. It is a medically necessary clinical intervention directly required to treat the patient’s diagnosed condition, restore baseline physical mobility, and prevent further functional degeneration.

Please approve the use of the patient’s Health Savings Account (HSA) / Flexible Spending Account (FSA)funds for these clinical somatic services.
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Practitioner Name
First Name   Last Name
MD DO DC PT
NPI #
Clinic Name
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LETTER OF MEDICAL NECESSITY

To Whom It May Concern / Claims Administrator:

Patient Name

Patient Clinical Diagnosis:

Treatment Plan & Justification:

Prescribed Frequency & Duration: