Using Your FSA/HSA for Nutrition Services

Many FSA/HSA plans cover nutrition services if they are deemed medically necessary for a diagnosed condition. To qualify, your healthcare provider must complete a Letter of Medical Necessity (LMN) stating that nutrition counseling is part of your treatment plan.

Below is a template you can provide to your doctor to sign. Once completed, submit it to your FSA/HSA administrator for approval.

📌 Instructions:

  1. Copy the template below.

  2. Ask your healthcare provider (doctor, nurse practitioner, or specialist) to fill it out and sign it.

  3. Submit the signed letter to your FSA/HSA provider for reimbursement eligibility along with your paid invoice.

⚠️ Note: Approval is determined by your FSA/HSA provider. If your request is denied, check if additional diagnoses or details are required.

LETTER OF MEDICAL NECESSITY

(For Nutrition Services – FSA/HSA Reimbursement)

Patient Name: __________________________
Date of Birth: __________________________
Provider Name: __________________________
Provider Credentials & NPI (if applicable): __________________________
Provider Phone: __________________________

To Whom It May Concern,

I am the treating physician/provider for [Patient’s Name], and I am recommending nutrition services as part of their treatment plan. Due to the patient’s documented medical condition(s), nutrition counseling is a necessary component of their care.

Medical Diagnosis/Condition(s):

☐ Hypertension (I10)
☐ Type 2 Diabetes (E11.9)
☐ Obesity (E66.9)
☐ PCOS (E28.2)
☐ Hyperlipidemia (E78.5)
☐ Irritable Bowel Syndrome (K58.9)
☐ Other: __________________________

Recommended Treatment:
☑ Nutrition Counseling to support condition management and improve patient health outcomes.
☑ Number of sessions to be determined based on patient’s needs.

Provider Statement:
In my professional opinion, nutrition counseling is medically necessary for the management and treatment of [Patient’s Name]’s condition(s). Therefore, I recommend they receive services from a qualified nutrition professional to improve their health and reduce the risk of further complications.

Provider Signature: __________________________
Date: __________________________