Sample Insurance Letter
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Sample Insurance Letter for
Neocate® Nutra
Date:_____________
___________________________
(Insurance Company Name)
____________________________
(Insurance Company Address)
Letter of Medical Necessity |
Dear Sir or Madam:
I am requesting insurance coverage and reimbursement for my patient _________________ (name), born on _____________________ (D.O.B.), for whom I have prescribed the use of Neocate® Nutra (manufactured by SHS International, distributed by Nutricia North America).
Neocate Nutra is a hypoallergenic semi-solid medical food specifically designed to meet the nutritional needs of children with severe cow milk protein or multiple food protein allergies who are unable to ingest a normal diet.
Neocate Nutra provides essential nutrients for children on a restricted diet. The elemental composition, which requires minimal digestion, is ideally suited for patients with compromised gastrointestinal function and food allergy related symptoms. Extreme food allergies often results in a delay in introducing solid foods, however, exploring new food textures is a critical milestone for oral motor development. Neocate Nutra allows patients with extreme food allergies to safely explore new textures and appropriately develop oral motor skills without the risk for an allergic reaction.
Neocate Nutra formula is medically necessary for my patient. Without the use of such a medical food, my patient may experience more complications, such as nutritional deficiencies /or delay in the development of proper feeding skills.
My patient NAME has been diagnosed with one or more of the following:
| Diagnosis |
ICD – 9 Code |
| □ bloody stool(s) |
578.1 |
| □ multiple food protein allergy |
558.1 |
| □ atopic dermatitis due to food allergy |
693.1 |
| □ allergic rhinitis due to food allergy |
477.1 |
| □ gastroesophageal reflux disease |
530.81 |
| □ malabsorption |
271.3 |
| □ failure to thrive/underweight |
783.22 |
| □ eosinophilic esophagitis |
530.13 |
| □ eosinophilic gastritis |
535.7 |
| □ eosinophilic gastroenteritis |
558.41 |
| □ eosinophilic colitis |
558.42 |
My patient's present weight is WEIGHT kg and height is LENGTH cm. He/She will require CALORIES kcal/ OUNCES ounces per day from Neocate Nutra. This amount may be adjusted as his/her nutritional needs change.
Neocate Nutra is not a drug, but the FDA classifies Neocate Nutra as an “Medical Food” which must be used under medical supervision and is not sold over the counter or at retail level. Therefore, Neocate Nutra has to be special ordered through a pharmacy or through Nutricia North America directly.
In the future, because of the close medical supervision required with the use of medical foods,NAME will need active and ongoing medical supervision to observe his/her growth and development and evaluate his/her dietary requirements.
Your approval of this request for assistance with medical care and reimbursement of the medical food would have a significant impact on this patient's health.
Sincerely,
______________________________________________
Signature
______________________________________________
Name
______________________________________________
Title
______________________________________________
Title – Center/Hospital/Institution/Practice
Cc: Current Growth Chart, Letter of Dictation, Reports, Prescription
Product and Reimbursement Information for Neocate Nutra
Name |
Packaging |
Calories per Can |
Reimbursement/ NDC Code |
HCPCS Code |
Neocate Nutra |
3 x 400 g (14 oz) |
1888 |
49735-0129-10 |
B4161 |
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