Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)

DATE

To:

Re: John Doe 

Dear Claims Department,

Your insured, John Doe, a 46 year old male, sought treatment in our office on June 15, 2005.  The following is a report of our findings.

SUBJECTIVE:
Mr. Doe’s chief complaints were headaches, soreness in jaw muscles.  He has been diagnosed with migraines by his physician, Dr. Physician, neurologist, and has been prescribed Imitrex, Relpax, Atenolol, and Topamax for management of his migraines.  Mr. Doe reports a history of ongoing headaches and jaw muscle pain, and always awakes with varying degrees of headache.  Mr. Doe’s stated symptoms are present 90% of his waking time, and worse in the mornings.  The pain ranges from dull to sharp, primarily focused in left anterior temple area.
The headaches are frequently accompanied by photophobia and phonophobia.

OBJECTIVE:
Moderate pain and tenderness to palpation of left temporal muscle.

ASSESSMENT:
In addition to Dr. Physician’s diagnosis of common migraine (346.10), my additional diagnosis is atypical facial pain (350.2).

PLAN:
Necessary treatment includes fabrication and insertion of an NTI-tss appliance (BC/BS 21110-52; ADA D7880).  The NTI-tss orthotic is an FDA approved device for prophylactic treatment of migraine pain (FDA 510(k) #K010876).  The NTI-tss system exploits the naturally protective nociceptive trigeminal inhibition reflex, which prevents the powerful temporalis muscles from contracting with full intensity while the patient is asleep, thereby reducing the neuromuscular component of the migraine attacks.

This report is to provide insurance carriers with the medical necessity for treatment.  All of the necessary patient information is provided herein for expedient claims processing.

Sincerely,

Dr. ______