LP Shield® Physician Cover Sheet

Attach to Letter of Medical Necessity — Made in the USA

For Healthcare Provider Review

LP Shield® is a male urinary leakage guard designed for management of:

Post-void dribbling
Light urinary incontinence
Residual urinary leakage

This product may fall under:

HCPCS Code: T4535

Disposable incontinence product, liner/shield, each. Completion of the attached Letter of Medical Necessity supports patient reimbursement submissions through FSA, HSA, or insurance plans.

Requested Information

Please complete:

Diagnosis and ICD-10 code (if applicable)
Recommended duration of use
Estimated monthly quantity
Signature and NPI

Thank you for supporting your patient's treatment plan.