LP Shield® Letter of Medical Necessity

For Insurance / FSA / HSA Submission — Made in the USA

Patient Information
Patient Name:
Date of Birth:
Diagnosis:
ICD-10 Code:
Medical Certification

I certify that the above patient is experiencing post-void dribbling and/or urinary incontinence requiring the use of a male urinary leakage guard. LP Shield® is medically necessary for management of urinary leakage and to maintain hygiene and quality of life.

Product Reference
Product: LP Shield® Male Urinary Leakage Guard
HCPCS Code (if applicable): T4535
Disposable incontinence product, liner/shield, each. Final coding determination subject to insurer review.
Recommended Duration of Use
3 Months
6 Months
12 Months
Ongoing as medically necessary
Frequency of Use
Daily
As Needed
Estimated Quantity Per Month:
Physician Information
Physician Name:
Practice Name:
Address:
NPI Number:
Phone:
Signature:
Date: