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FSA & HSA reimbursement

Letter of Medical Necessity

Fill in your part below, print the two pages, and take them to your physician, chiropractor, or physical therapist. They complete the clinical sections and sign. Everything stays in your browser — nothing you type is sent to us or stored.

Works for husbandpillow.com orders. No order number? The letter still generates below.

You fill in — prints already completed

Your details, what you bought, and the receipt. Saves your provider time.

Your provider fills in — prints blank

Diagnosis, duration of need, clinical rationale, and signature. We never complete these.

1 · About you

Administrators match the letter to the cardholder's name on file.

2 · What you bought

No order number? Leave it blank — the letter still generates, and your administrator will match it to the receipt you submit alongside.

We don't decide medical necessity — your provider does. Diagnosis, duration of need, and the signature print blank for a licensed practitioner. Don't tick those boxes yourself; a letter completed by the patient will be rejected.

Printing works without an account. Nothing is stored unless you choose to save.

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Your letter · 2 pages

Start typing — the letter fills in as you go

POSITIONING DEVICE RECOMMENDATION

Letter of Medical Necessity · FSA / HSA substantiation  |  Form CIQ-LMN-2026  |  Rev 2.0  |  HCPCS E0190
APATIENTCompleted by the patient
BPROVIDERCompleted by the provider
CCLINICAL DIAGNOSIS  (ICD-10) Provider — check every condition the device addresses

Cervical & neck

M54.2 Cervicalgia
M50.20 Cervical disc disorder
M54.12 Cervical radiculopathy
M47.812 Cervical spondylosis
G54.0 Brachial plexus disorder

Lumbar & low back

M54.50 Low back pain
M54.40 Sciatica
M51.16 Lumbar disc herniation
M47.816 Lumbar spondylosis
M48.06 Lumbar spinal stenosis

Shoulder & upper extremity

M75.10 Rotator cuff syndrome
M75.00 Adhesive capsulitis
M25.511 Shoulder pain, right
M25.512 Shoulder pain, left
G56.00 Carpal tunnel / nocturnal paresthesia

Hip, coccyx & sacral

M53.3 Coccydynia
M54.30 Sciatic nerve pain
M25.551 Hip pain, right
M25.552 Hip pain, left

Sleep & reflux positioning

G47.33 Obstructive sleep apnea
G47.30 Sleep apnea, unspecified
K21.0 GERD with esophagitis
K21.9 GERD without esophagitis

Recovery, circulation & pregnancy

Z98.89 Post-surgical positioning
I87.2 Venous insufficiency
O26.89 Pregnancy-related pain
M62.830 Muscle spasm of back

Other

ICD-10 Description
DDEVICE Purchased item pre-filled · provider may add others
✓DevicePositioning function HCPCSSize / configuration
EDURATION OF NEED & RATIONALE Required — letters without a duration are rejected
Expected duration of need 3 months 6 months 12 months Indefinite
Onset of condition < 3 months 3–12 months > 12 months
How the device treats the condition
FPROVIDER ATTESTATIONSignature required

I am a licensed healthcare provider. I have evaluated the patient named in Section A and recommend the device(s) checked in Section D to treat, mitigate, or alleviate the condition(s) checked in Section C. In my clinical judgement these items would not have been purchased but for that medical condition, and they are not for general comfort or general health use.

Total devices recommended in Section D (write in): — entered by the provider so items cannot be added after signing.

This is not a pharmacy prescription and is not an order for insurance-billed durable medical equipment. It is a Letter of Medical Necessity supporting reimbursement from a Flexible Spending Account or Health Savings Account under IRC §213(d). Eligibility is determined solely by the plan administrator; reimbursement is not guaranteed. Hit Notion LLC d/b/a ComfyIQ is the seller of the items listed and makes no determination of medical necessity. Submit with the itemized receipt on page 2.
Patient: scan to reprint this letter or register your warranty.
CIQ-LMN-2026

ITEMIZED RECEIPT

Supporting documentation for reimbursement
Submit together with page 1
PURCHASE DETAILCompleted by the patient
Purchaser
—
Retailer
—
Order number
—
Date of purchase
—
Prepared
—
ItemIdentifiersQty EachAmount
—— —— —
Tax & shipping —
Total paid—
INTENDED USE OF THE DEVICE

This itemized summary was generated by the purchaser from their own order details. Where an order number could not be verified against our records, the amounts shown are as entered by the purchaser and should be submitted with the original retailer receipt. Hit Notion LLC d/b/a ComfyIQ, Madison Heights, Michigan · cs@comfyiq.com

After your provider signs — how to submit it

This is the part that happens away from our site. Come back here any time — reprinting is free and nothing expires.

1 · Where to submit

Log in to your plan's app or portal (the one on the back of your FSA/HSA card) and search for "reimbursement claim" or "submit a claim". Every administrator has one; most accept photos or PDFs.

2 · What to attach

Both printed pages: the signed Letter of Medical Necessity and the itemized receipt. If you paid on a marketplace, include the retailer's original receipt too.

3 · A short message you can paste

"Hello — I'm submitting a claim for an orthopedic positioning device (HCPCS E0190). Attached are a Letter of Medical Necessity signed by my provider and the itemized receipt. Please let me know if anything else is needed."

4 · If it comes back rejected

The two most common causes are a missing duration of need and a missing provider signature or date — both have dedicated fields on our form. Check they are filled in, then resubmit. Your plan administrator makes the final decision on every claim; if they give a different reason, email us at cs@comfyiq.com and we'll help you read it.

GOT QUESTIONS? WE'VE GOT YOU COVERED.

GOT QUESTIONS? WE'VE GOT YOU COVERED.