Licensed in 50 states
License #SAMPLE
May 12, 2026
Re: Letter of Medical Necessity
To whom it may concern:
I am the treating physician for the above patient. Based on my clinical evaluation, the item described below is medically necessary for the diagnosis, treatment, or mitigation of a documented condition, and is recommended as part of this patient’s care plan.
Diagnosis
Type 2 diabetes mellitus with documented glycemic variability (ICD-10 E11.x). Most recent A1c outside target range despite adherence to current regimen.
Clinical reasoning
- Continuous glucose data is required to identify post-prandial excursions and nocturnal hypoglycemia not captured by fingerstick testing.
- Real-time monitoring is expected to improve time-in-range and reduce avoidable acute events.
- Conservative measures alone have not achieved adequate control.
Requested intervention & duration
CGM device and consumable sensors, 12-month authorization, to be reassessed at the next visit. In my professional judgment this expense qualifies as medical care under IRS §213(d).