[Physician’s Letterhead]
Date: [Insert Date]
To: [Insurance Company Name]
Re: Letter of Medical Necessity for CleanSpace HALO Respirator
Patient: [Patient Full Name, DOB]
Policy Number: [Policy #]
Dear Medical Review Team,
I am writing to request coverage and reimbursement for a CleanSpace HALO powered air-purifying respirator (PAPR) for my patient, [Patient Name], who has been diagnosed with [Asthma (ICD-10 J45.x) and/or Chronic Obstructive Pulmonary Disease (COPD) (ICD-10 J44.x)].
Asthma and COPD are chronic respiratory diseases that can cause breathing difficulties, airway inflammation, and vulnerability to environmental triggers such as allergens, dust, fumes, smoke, and other airborne particulates. Despite ongoing medical management, my patient continues to experience respiratory symptoms that limit daily functioning and increase the risk of acute exacerbations.
The CleanSpace HALO is medically necessary for this patient because it provides:
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Medical-grade HEPA filtration (99.97%), which significantly reduces exposure to airborne triggers known to worsen asthma and COPD symptoms.
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Positive-pressure airflow, which reduces the work of breathing and eases respiratory strain.
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Lightweight, compact design that enables comfortable daily use, even during extended wear.
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NIOSH-approved, IP66-rated device, ensuring compliance with healthcare safety standards and infection-control requirements.
By supporting cleaner airflow and reducing breathing fatigue, the CleanSpace HALO will help my patient avoid exacerbations, reduce emergency interventions, and maintain a higher quality of life.
I respectfully request that you approve coverage for this prescribed medical device under my patient’s durable medical equipment (DME) or respiratory support benefits.
Thank you for your prompt review. Please contact me if additional documentation is required.
Sincerely,
[Physician Name, Credentials]
[Practice/Clinic Name]
[Contact Information]
