[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 Nemaline Myopathy (ICD-10 Code: G71.2).
Nemaline Myopathy is a neuromuscular disorder that causes muscle weakness, including weakness of the respiratory muscles, leading to breathing difficulties and chronic fatigue. My patient experiences ongoing respiratory strain and requires continuous support to alleviate breathing fatigue and protect against environmental triggers.
The CleanSpace HALO is medically necessary for this patient because it provides:
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Positive-pressure airflow, which reduces the patient’s work of breathing and eases respiratory fatigue.
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Medical-grade HEPA filtration, protecting against dust, allergens, and pathogens that could worsen respiratory compromise.
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Lightweight, belt-free design, enabling extended wear without additional muscle strain.
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NIOSH-approved, hospital-grade device, ensuring compliance with infection-control and safety standards.
Without this support, my patient is at increased risk of recurrent respiratory infections, hospitalizations, and further decline in quality of life. The HALO will directly reduce these risks and provide essential support for daily living.
I respectfully request approval for coverage of the CleanSpace HALO under durable medical equipment (DME) or respiratory support benefits.
Sincerely,
[Physician Name, Credentials]
[Practice/Clinic Name]
[Contact Information]
