FSA Letter Of Medical Necessity
Standard Items Required in a Letter of Medical Necessity
Patient identifiers (full name, DOB, last 4 SSN or Member ID)
Diagnosis & ICD-10 code(s) (e.g., M54.5 – Low-back pain; M79.1 – Myalgia)
Treatment prescribed – Name of the session” (e.g Thai Sport Massage)
Clinical rationale – how massage will “treat, mitigate, or prevent” the condition.
Frequency & duration – e.g., “60-minute sessions, 1× week for xx weeks,
re-eval after xx weeks
Provider credentials & license (MD, DO, DC, PA, NP) + NPI
Verifies scope of practice.
Date & signature (wet or e-signature)
Establishes validity window (most FSAs honor for 12 months).
Acceptable ICD10 Diagnostic Codes
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