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Conditional

Requires Letter of Medical Necessity (LOMN)

Is Water Purification FSA/HSA Eligible?

Category: Medical Equipment

How to Get Approved

Only if prescribed for specific medical condition.

The Fast Way

Don't have a doctor?

Get instant approval online for $30. Skip the appointment — a licensed physician reviews your request and issues your LOMN within 24-48 hours.

24-48 hour turnaround
Board-certified physicians
Get Instant Approval — $30

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Free LOMN Template

Copy this template and bring it to your doctor. They'll need to customize it with your diagnosis and sign it.

LETTER OF MEDICAL NECESSITY Date: [DATE] To Whom It May Concern, I am writing to certify that Water Purification is medically necessary for my patient: Patient Name: [PATIENT NAME] Date of Birth: [DOB] Diagnosis: [ICD-10 CODE AND DESCRIPTION] Medical Justification: Only if prescribed for specific medical condition. I have prescribed this item as part of the patient's treatment plan, and it is not for general health or cosmetic purposes. If you have any questions, please contact my office. Sincerely, [PHYSICIAN SIGNATURE] [PHYSICIAN NAME, MD] [PRACTICE NAME] [NPI NUMBER] [PHONE NUMBER]

Submit the signed letter to your FSA/HSA administrator along with your receipt.

Quick Facts

Status
Conditional
LOMN Required
Yes
Category
Medical Equipment
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