Letter of Medical Necessity (LMN)
To:
From:
Date:
Re:__________________________| DOB: _____________ | Policy #: _______________
Patient Clinical Status
The above-referenced patient is a _______-day-old infant with a diagnosis of Neonatal Jaundice (ICD-10: P59.9).
Current Total Serum Bilirubin (TSB):______ mg/dL at ______Age in Hours
Gestational Age:
Risk Factors: None
Feeding Status: Breastfeeding, Formula supplemented, or Both
Clinical Justification for Home Phototherapy
Based on the current AAP Clinical Practice Guidelines, this infant requires intensive phototherapy to prevent further elevation of bilirubin and the potential risk of bilirubin encephalopathy.
I have determined that Home-Based Phototherapy is the most appropriate and cost-effective level of care for this patient because:
The infant is clinically stable, afebrile, and feeding well.
Home treatment prevents a high-cost hospital readmission or prolonged NICU stay.
It facilitates maternal-infant bonding and supports the continuation of breastfeeding.
The family has been assessed as capable of following the treatment plan under professional nursing supervision.
Prescribed Services & Equipment
I am ordering the following medical services and equipment to be provided by Lumi: Heal At Home Newborn Phototherapy:
HCPCS E0202: Phototherapy (bilirubin) light with photometer (Intensive LED/Fiberoptic system).
HCPCS S9098: Home visit, state-licensed, for utilization of home phototherapy; per diem (includes professional nursing assessment, bilirubin monitoring, and parental education).
Treatment Plan
Frequency: Continuous intensive phototherapy (24 hours/day), except for feeding and diaper changes.
Duration: Estimated 1–3 days, pending daily TSB results.
Monitoring: Professional nursing assessment and TSB labs every 12-24 hours.
Discontinue phototherapy when the TSB level is < 2-3 mg/dL from start of treatment.
Physician Signature: _______________________________________
Physician Name (Printed): ___________________________________
NPI Number: _____________________________________________
Phone: __________________________________________________
