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SAMPLE FORM:COPY, PASTE and EDIT.
Dear Patient:
Medicare
will only pay for services that it determines to be “reasonable and necessary” under section 1862(a) (1) of Medicare law.
If Medicare determines that a particular service, although it would otherwise be covered, is not “reasonable and necessary”
under Medicare program standards, Medicare will deny payment for that service. I believe that, in your case, Medicare is likely
to deny payment for:
CPT Code_________________ Procedure (Specify) _________________________
______________________________________________________________________
for
the following reasons: _________________________________________________
______________________________________________________________________
______________________________________________________________________
Beneficiary
Agreement:
I have been notified by my physician that he or she believes that, in my case, Medicare is likely to deny
payment for the services identified above for the reasons stated. If Medicare denies payment, I agree to be personally and
fully responsible for payment.
_______________________ __________________________________
Date Medicare
Beneficiary
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