[Date]

[Insurance Company Name]
[Insurance Company Address]

RE: Letter of Medical Necessity for Health Coaching Services

Patient Name: [Patient Name]
Date of Birth: [Patient Date of Birth]
Policy/Member ID: [Patient ID Number]

Dear Plan Administrator:

I am writing on behalf of my patient to provide a letter of medical necessity supporting a referral for out-of-pocket health coaching services with Tamara R. Pringle of Pringle Personal Health LLC, EIN 39-3441424. These services are essential for the treatment of a medical condition, qualifying the expense as a “qualified medical expense” eligible for reimbursement through the patient’s Health Savings Account (HSA) or Flexible Spending Account (FSA), consistent with recent guidance provided to the National Board of Certified Health & Wellness Coaching (NBHWC) and IRS guidance under Internal Revenue Code sec. 213(d) regarding medical care expenses..

Patient Clinical Summary and Medical Necessity:

This patient is currently under my care for the following diagnosed medical conditions: ***

[SPECIFY THE APPLICABLE MEDICAL DIAGNOSIS:]  

• hyposexual desire disorder, causing personal distress and for ≥6 months: F52.0
• female sexual interest / arousal disorder: F52.22
• decreased libido without distress: R68.82
• dyspareunia: F52.6
• menopause symptoms: N95.1
• other sexual disorders: F66 (sexual relationship disorder)
• genitourinary syndrome of menopause: N95.2
• stress in the relationship with a spouse:  Z63.0

Despite traditional medical interventions, the patient has demonstrated a lack of progress in sustained behavioral change and management of their symptoms which continues to impede progress toward treatment goals.

Specifically, this patient needs assistance with addressing underlying behavioral and lifestyle factors contributing to the diagnosed condition(s) and managing the physical and emotional impact of these conditions in order to improve treatment adherence, symptom management, and overall clinical outcomes. 

This coaching referral is to a qualified health coach to provide one-on-one coaching services aimed at developing sustainable habit changes, improving communication skills and maximizing the benefit of pharmacologic and medical interventions that are part of the patient’s ongoing medical treatment plan.

Health and wellness coaching, provided by a qualified professional, is a critical, non-pharmacological tool that focuses on sustained behavioral change, accountability, and the development of self-management strategies. This intervention is necessary to address the root lifestyle and personal factors contributing to this patient’s condition and is crucial for the effective treatment of the diagnosed condition(s) listed above.

These services are prescribed as part of the patient’s treatment plan for a defined period of time. Recommended duration of health coaching services: twice monthly sessions for up to six months and then to reassess as clinically indicated.

Given the IRS guidance shared with the NBHWC that “out-of-pocket costs of health and wellness coaching services can be a ‘qualified medical expense’ if the services are provided for the treatment or prevention of a disease,” I firmly attest that the referred health coaching services meet this requirement for this patient.

These services are not being recommended for general wellness or personal development, but specifically as a therapeutic intervention to support treatment of the diagnosed medical condition(s) noted above.

I urge you to approve the reimbursement of this patient’s health coaching expenses via their HSA or FSA funds, as this service is medically necessary and reasonable to help them achieve optimal health outcomes and manage their medical conditions. Please feel free to contact me should you require any further clinical information.

Sincerely,

[Physician’s Signature][Physician’s Printed Name]
[Physician’s Title/Specialty]
[Clinic/Practice Name]
[NPI Number]
[Contact Phone Number]
[Contact Email Address]