HSA/FSA Letter of Medical Necessity Template — Pessary (A4562) — Free Download
Free HSA/FSA Letter of Medical Necessity — Pessary Template
A fill-in-the-blank template your gynecologist, urogynecologist, primary care provider, or midwife can sign to unlock pre-tax HSA/FSA reimbursement or Medicare Part B coverage for your silicone ring pessary. Free. No email required.
Why you may need a Letter of Medical Necessity (LMN)
A pessary is an FDA Class II medical device under HCPCS code A4562 — meaning it qualifies as a medical expense under IRS Section 213(d), Medicare Part B (durable medical equipment), and most private-insurance flexible spending plans. But to use pre-tax dollars or file for reimbursement, your plan administrator typically wants a signed statement from your provider confirming: (a) you have a diagnosed condition, (b) the pessary treats that condition, and (c) it's medically indicated.
That statement is called a Letter of Medical Necessity (LMN). Most gynecologists will sign one at your next visit if you bring the language pre-drafted. This page gives you that language.
Step-by-step: how to use this template
- Copy the template text below into a Word doc — OR download the printable PDF (link above).
- Fill in the fields highlighted in yellow yourself (your name, DOB, address, dates).
- Bring the pre-filled letter to your next visit. Ask your gynecologist / urogynecologist / midwife / primary care provider to review, sign, and add their NPI + license number.
- Submit the signed LMN to your HSA/FSA administrator (Optum, HealthEquity, Fidelity, PayFlex, Navia, etc.) — or attach it to your Medicare DME claim if using Medicare Part B.
- Keep a copy for your tax records. Also save the SciMed order receipt — it lists HCPCS A4562 for reimbursement documentation.
The template — copy and edit
To: HSA/FSA Plan Administrator or Insurance Claims Department
Re: Medical Necessity for Vaginal Pessary (HCPCS A4562)
Patient Information
Name: [Patient Full Legal Name]
Date of Birth: MM / DD / YYYY
Address: [Street, City, State, ZIP]
Insurance / HSA / FSA Account: [Account or Plan ID]
To Whom It May Concern:
I am the treating provider for the above-named patient. This letter is submitted to confirm the medical necessity of a vaginal ring pessary (HCPCS code A4562 — Pessary, non-rubber, any type), an FDA-cleared Class II medical device under 21 CFR 884.5350.
Diagnosis:
The patient has a diagnosis of [e.g., pelvic organ prolapse ICD-10 N81.4], with symptoms including [e.g., vaginal pressure, urinary incontinence, discomfort during standing/walking, difficulty with bowel evacuation]. Onset of symptoms: approximately MM / YYYY.
Recommended Treatment:
A silicone ring pessary is the appropriate first-line non-surgical treatment for this diagnosis. This device is worn intravaginally to provide structural support to the pelvic organs. Silicone pessaries are recommended in preference to older PVC devices per the peer-reviewed evidence (Int Urogynecol J, 2024; DOI 10.1007/s00192-024-05933-x) and are supported for patient self-management (TOPSY RCT, NCBI Bookshelf NBK603994, 2024).
Device details:
Manufacturer / Supplier: SciMed Scientific Equipment LLC
Product: Silicone Ring Pessary (with or without support membrane, per clinical need)
HCPCS Code: A4562
FDA Classification: Class II, 510(k) Cleared, Product Code HHN
Anticipated Cost: $49.99 per device (typical replacement every 12–24 months)
Duration of Treatment:
Ongoing / indefinite for as long as the patient's clinical presentation warrants non-surgical management. Replacement pessaries anticipated every [12 / 18 / 24] months.
Alternatives Considered:
Surgical repair (colporrhaphy, hysterectomy, sacrocolpopexy) is not appropriate at this time due to [e.g., patient preference, surgical risk, desire to preserve future childbearing, mild-to-moderate disease severity, or as bridging therapy]. Pelvic floor physical therapy has been recommended as adjunct.
Based on my clinical evaluation, I certify that this vaginal pessary is medically necessary for this patient. Please approve reimbursement under the patient's HSA, FSA, HRA, or Medicare Part B benefits as applicable.
Sincerely,
[Provider Full Name, Credentials — e.g., Jane Smith, MD]
Signature: _______________________________
NPI Number: [10-digit NPI]
State License #: [License number and state]
Practice Name: [Clinic / hospital name]
Practice Address: [Street, City, State, ZIP]
Phone: [XXX-XXX-XXXX]
Date: MM / DD / YYYY
Which HSA/FSA administrators typically accept this format?
The IRS does not publish a rigid template — administrators just want to see: patient name, diagnosis, recommended treatment, duration, and a licensed provider's signature + NPI. The template above meets those elements. Confirmed compatible with the standard forms used by:
- HSA/FSA: Optum Financial, HealthEquity, Fidelity NetBenefits, PayFlex (Aetna/CVS), Navia Benefits, WageWorks/HealthEquity, Discovery Benefits, Alerus, Voya, BenefitWallet
- Medicare Part B (DME): Attach to your DME supplier's paperwork when billing HCPCS A4562. Most regional MACs process A4562 at $69–$89 (2026 CMS DMEPOS Fee Schedule).
- Employer HRA: Most Section 105 plans accept LMN letters as substantiation.
Frequently asked questions
Do I need a prescription to buy a pessary from SciMed?
No. A pessary is an FDA Class II device — no prescription is required to purchase. The LMN is only required if you want to use pre-tax HSA/FSA dollars or file for Medicare / insurance reimbursement.
How long is an LMN valid?
Most HSA/FSA administrators accept an LMN as valid for 12 months, though some allow up to 3 years for chronic/ongoing conditions like pelvic organ prolapse. Ask your specific plan administrator.
Can my primary care doctor sign this — or does it have to be a specialist?
Any licensed prescribing provider can sign (MD, DO, NP, PA, midwife). It does not need to be a specialist, though a gynecologist or urogynecologist letter carries the most weight for insurance approval.
Does Medicare cover the pessary itself, or just the fitting?
Medicare Part B covers HCPCS A4562 (the device) at $69–$89 depending on your MAC. Fitting visits are billed separately by your provider under E&M codes. SciMed's direct price is $49.99 — so a Medicare-covered patient may be reimbursed for MORE than they paid.
What ICD-10 codes commonly appear with pessary use?
N81.10 (cystocele, unspecified), N81.11 (cystocele, midline), N81.4 (uterovaginal prolapse, unspecified), N81.6 (rectocele), N81.89 (other female genital prolapse), N39.3 (stress incontinence). Your provider selects the correct code.
Is this template a legal or medical document?
No. It is a starting draft. Only a licensed provider signing the letter can attest to medical necessity for your case. This template does not constitute medical, tax, or legal advice.