Free Letter of Medical Necessity (LMN) Generator — FSA & HSA Eligible

1. Patient InformationStep 1 of 3

Patient Full Name

Date of Birth

2. Medical Diagnosis & ItemStep 2 of 3

Primary Diagnosis / Clinical Condition

ICD-10-CM Diagnosis Code

Authorized Treatment Duration

Prescribed Medical Equipment / Treatment

Usage Frequency & Treatment Regimen

Clinical Rationale (Why item is medically necessary)

3. Prescribing Doctor & PracticeStep 3 of 3

Provider Name

Title / Specialty

Clinic / Hospital Name

National Provider ID (NPI)

State License Number

Clinic Address & Phone

IRS §213(d) Compliant Preview

Metro Health & Wellness Clinic

1200 Health Parkway, Suite 400, Chicago, IL 60611 • Tel: (312) 555-0198

Attending: Dr. Sarah Lin, MD (Board Certified Internal Medicine) • NPI: 1487293012

Confidential Medical Document

October 13, 2026

Letter of Medical Necessity

RE: Request for Flexible Spending Account (FSA) / Health Savings Account (HSA) Reimbursement Approval under IRC §213(d)

Patient Name:

Alex Mercer

Date of Birth:

1988-06-14

Medical Diagnosis:

Chronic Primary Insomnia / Circadian Rhythm Sleep Disorder

ICD-10-CM Code:

F51.01

1. Prescribed Item / Medical Device

Biometric Sleep & Physiological Monitor (Oura Ring / WHOOP)

2. Recommended Frequency & Treatment Duration

Dosage / Frequency: Daily continuous biometric recording and nocturnal monitoring
Treatment Duration: 12 Months (Standard IRS Annual Authorization)

3. Clinical Rationale & Necessity

Continuous biometric monitoring of basal body temperature oscillations, sleep architecture stages, heart rate variability (HRV), and nocturnal autonomic recovery is clinically necessary to titrate behavioral sleep interventions and monitor circadian rhythm disturbances.

4. Statutory Compliance & IRS Affirmation

“Pursuant to Internal Revenue Code §213(d) and IRS Publication 502, I certify that this patient is under my professional medical care for the diagnosis stated above. The equipment, item, or service prescribed herein is medically necessary to mitigate, treat, alleviate, or prevent this specific diagnosed medical condition. It is not prescribed for general health, fitness, comfort, recreation, or cosmetic reasons, and represents an integral component of the ongoing medical management of this patient.”

[Physician Signature]

Dr. Sarah Lin, MD

Board Certified Internal Medicine

NPI: 1487293012 • Lic: IL-036184920

October 13, 2026

Date of Certification

📋 How to Use This Letter of Medical Necessity

Print or Copy: Print this document or copy the text to your patient portal (MyChart, Epic, AthenaHealth).
Physician Signature: Ask your doctor, physician assistant, or nurse practitioner to sign and date the document.
Submit with Itemized Receipt: Upload both the signed LMN and the merchant invoice or receipt directly to your FSA/HSA portal (e.g. HealthEquity, Optum, FSAFEDS, WEX).
Annual Renewal: The IRS requires LMNs for ongoing dual-purpose expenses to be updated once every 12 months.

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