[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-276691-105":53,"doc-detail-276691-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","sample-letter-of-medical-necessity-authorization-for-qsymia-use","Sample Letter of Medical Necessity - Authorization for Qsymia Use","","Sample medical-necessity letter template for documenting and requesting coverage for Qsymia® (phentermine and topiramate extended-release) capsules CIV for a specific patient. The letter includes prescriber and plan member information, patient clinical history, diagnosis rationale, and treatment intent, followed by a medical necessity statement supporting reimbursement. A comprehensive form section captures ICD-10 diagnoses, BMI and related metrics, adjunct therapies and durations, and prescriber identifiers, signature, and required dates.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/sample-letter-of-medical-necessity-authorization-for-qsymia-use/276691/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/sample-letter-of-medical-necessity-authorization-for-qsymia-use/276691.png","ImageObject",442,249,{"name":88,"@type":89},"Arica Lee","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-04","2026-09-15",true,{"@type":98,"interactionType":99,"userInteractionCount":25},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is needed to request authorization for Qsymia using this template?","Question",{"text":108,"@type":109},"It requires patient plan identifiers, member details, the patient’s diagnosis history and rationale, and a statement that Qsymia is medically necessary for the patient. It also includes prescriber and practice information to support the request.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which clinical items are captured in the medical necessity form section?",{"text":113,"@type":109},"The form collects ICD-10 diagnosis codes related to weight-related comorbidities, plus BMI and anthropometric measures. It also includes adjunct therapies and their duration, such as calorie-restricted diet, weight-loss programs, and pharmacotherapy.",{"name":115,"@type":106,"acceptedAnswer":116},"What attestations and sign-off are included at the end of the document?",{"text":117,"@type":109},"The template includes a certification that the therapy is medically reasonable and necessary, along with the prescriber’s signature and date. It also indicates required provider identifiers and signature fields.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},276691,1789494845,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":25,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":9},8796096645457,"https://ap-avatar.wpscdn.com/avatar/800003749518d68ffe3?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345340919836971","Sample Letter of Medical Necessity  \nPlease translate this sample letter on to your own physician’s letterhead before printing.  \n[Date]  \n[ Prescriber Name]  \n[Your Address]  \n[Your City, State, ZIP][Your phone number][Tax ID Number][DEA Number]  \n[Name of Rx Plan][Address of Rx Plan]  \nRe: Authorization for Qsymia® (phentermine and topiramate extended-­‐release) capsules (CIV) use for [ Patient’s name]  \nMember ID:  \nGroup \\#:  \nRx Bin\\#:  \nDate of Birth:  \nTo Whom It May Concern:  \nI am writing to document the medical necessity of Qsymia ® (phentermine and topiramate extended-­‐release) capsules CIV for my patient,[patient’s name] . The enclosed documentation provides information about the patient’s medical history, diagnosis, and my treatment rationale.  \nQsymia was FDA approved on July 17, 2012 as an adjunct to a reduced-­‐calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/ m2 or greater (overweight) in the presence of at least one weight-­‐related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia. [Patient’s name] was originally diagnosed with [disease(s)] in [year(s) of diagnosis(es)] .[Include a description of investigation leading to diagnosis(es) and any treatments that have never worked or stopped working and those to which patient response was inadequate.]  \nI plan to treat [patient name] with Qsymia. [Include statement about why Qsymia is right for the patient] .  \nIn my professional opinion, Qsymia is medically necessary and is the appropriate treatment choice for my patient at this time. Thus, Qsymia should qualify for reimbursement under my patient’s benefit plan. Please feel free to contact me if you require additional information.  \nSincerely,  \nPhysician Name, MD and Signature  \nCC: [patient’s name]  \nRef: Qsymia® (phentermine and topiramate extended-­‐release) capsules CIV package insert, 2014  \n100427.02-USP  \nMedication*   □ New Therapy □ Continuing Therapy Dose*    \nPatient Information  \nLast Name:*   First Name:*   Birth date*:   Gender*: □ Male □ Female Street:   City:   State*:   ZIP:   Home phone: (  )   Work/cell phone: (  )   Insurance No.:   Policy/group No.:   Policyholder Name:   Policyholder birth date*:    \nBody Mass Index (BMI) (kg/m2):  Waist Circumference (in.):  Height (in.):  Weight (lbs.):   \nMedical Necessity Information  \nICD-10 CODE-Diagnoses & Weight-related comorbidities (Check all that apply):  \n□ E11 .65 Type 2 Diabetes Mellitus, with hyperglycemia  \n□ E11 .8 Type 2 DM, with unspecified complications  \n□ Z83.3 Family history of type 2 DM  \n□ E34 .9 Endocrine disorder  \n□ E78 .4 Other Hyperlipedemia  \n□ E66 .2 Morbid Obesity with alveolar hypoventilation  \n□ E66 .01 Morbid obesity (excess calories)  \n□ E66 .3 Overweight  \n□ E65 Localized adiposity  \n□ F33.40 Major depressive disorder  \n□ G47 .33 Obstructive sleep apnea  \n□ I10 Hypertension, essential (unspecified)  \n□ Z82.49 Family history of hyertension  \n□ M19 .93 Osteoarthritis, secondary  \n□ R73 .01 Impaired fasting glucose  \n□ Other Specify by ICD-10-CM    \n□ Other Specify by ICD-10-CM    \n□ Other Specify by ICD-10-CM    \n□ Other Specify by ICD-10-CM    \nAdjunct Therapies & Duration (Check all that apply):  \n□ Calorie-restricted diet   months  \n□ Commercial weight-loss programs   months  \n□ Dietary Supplements   months  \n□ Gastric procedure Date    \n□ Nutritionist   months  \n□ MD-directed program   months  \n□ Physical activity program   months  \n□ Weight-loss pharmacotherapy   months  \n□ Other :    \n□ Other :    \n□ Other :    \n□ Other :    \nPrescriber’s last name*:   First name*:   Practice name:  Speciality:   Street*:  City*:   State*:   ZIP*:   Phone: (  )   Fax: (  )   Prescriber Tax ID :   Prescriber NPI†:   DEA \\#:   Group NPI   State license \\#*:   PTAN† †:    \nPlease read the FDA-approved label for Qsymia before prescribing. If the indication for which you are prescribing Qsymia is n","cbCaio9Yq8k5rNg5","https://ap.wps.com/l/cbCaio9Yq8k5rNg5","pdf",304442,"English","# Re: Authorization for Qsymia Use\n## Letterbody and medical necessity rationale\n## Patient and prescriber information form","[{\"question\":\"What information is needed to request authorization for Qsymia using this template?\",\"answer\":\"It requires patient plan identifiers, member details, the patient’s diagnosis history and rationale, and a statement that Qsymia is medically necessary for the patient. It also includes prescriber and practice information to support the request.\"},{\"question\":\"Which clinical items are captured in the medical necessity form section?\",\"answer\":\"The form collects ICD-10 diagnosis codes related to weight-related comorbidities, plus BMI and anthropometric measures. It also includes adjunct therapies and their duration, such as calorie-restricted diet, weight-loss programs, and pharmacotherapy.\"},{\"question\":\"What attestations and sign-off are included at the end of the document?\",\"answer\":\"The template includes a certification that the therapy is medically reasonable and necessary, along with the prescriber’s signature and date. It also indicates required provider identifiers and signature fields.\"}]","Sample Letter of Medical Necessity - Authorization for Qsymia Use | PDF"]