[Physician letterhead — name, practice, address, phone]
Date: ___________________
To: HSA / FSA Plan Administrator
Re: Letter of Medical Necessity for [patient full name], DOB [__/__/____]
To Whom It May Concern,
I am the treating physician for the patient identified above. Based on my clinical evaluation, the medication described below is medically necessary for the treatment of a diagnosed disease, not for general well-being, cosmetic, or non-medical purposes. This letter supports reimbursement of out-of-pocket costs from the patient's HSA / FSA under IRS §213(d) (qualified medical expense).
Patient information
- Height: [___ cm / ___ ft ___ in]
- Weight: [___ kg / ___ lb]
- BMI: [___ kg/m²]
- Relevant comorbidities: [type 2 diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, cardiovascular disease, NAFLD]
Diagnosis (ICD-10)
- Primary diagnosis: [E66.01 — morbid obesity / E66.9 — obesity, unspecified / E11.x — type 2 diabetes mellitus]
- BMI status code: [Z68.4x for BMI ≥ 40, Z68.3x for BMI 30 – 39.9]
Prescription
- Medication: [Wegovy / Zepbound / Saxenda — brand, strength, formulation]
- NDC: [National Drug Code]
- Dose & titration: [per FDA label, escalated to maintenance dose over ___ weeks]
- Expected duration: chronic / long-term therapy
Clinical rationale
The patient meets the FDA-approved indication for this medication. They have engaged in lifestyle interventions (dietary modification, increased physical activity, behavioural counselling) and have not achieved clinically meaningful weight reduction or glycaemic control on those measures alone. Pharmacotherapy is medically appropriate given the patient's BMI and comorbidity profile and is expected to reduce long-term cardiovascular and metabolic risk.
Request
Please reimburse the patient's out-of-pocket expense for this prescription as a qualified medical expense under IRS Publication 502 and §213(d). The medication is being prescribed in accordance with its FDA-approved indication, not for cosmetic weight loss or general well-being.
Please contact my office at the phone number above if additional documentation is required.