Pepdite Junior - Sample Insurance Letter
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Sample Insurance Letter for
Peptide Junior®
Date:_____________
___________________________
(Insurance Company Name)
____________________________
(Insurance Company Address)
____________________________
(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 Pepdite Junior ® formula (manufactured by SHS International, distributed by Nutricia North America).
Pepdite Junior is a semi-elemental medical food consisting of free amino acids and low molecular weight peptides. It is specifically designed for children over one year of age with gastrointestinal impairment due to multiple food protein intolerance or other medical conditions affecting the gastrointestinal tract. Its unique formulation provides complete nutrition and can be the sole source of nutrition. Pepdite Junior has a semi-elemental composition, which requires minimal digestion, thus ideally suited for patients with compromised gastrointestinal function.
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 |
Pepdite Junior is not a drug, but considered a medical food, which must be used under medical supervision and is not sold over the counter or at retail level. Therefore, Pepdite Junior has to be special ordered through a pharmacy or through Nutricia North America directly.
Pepdite Junior formula is medically necessary for my patient, and will provide the proper nutrition management for this patient. Without the use of an semi-elemental formula, my patient may experience more complications, which can result in hospitalization and/or costly parenteral nutrition.
Therefore, I am prescribing the following: (Please see below for the product and reimbursement codes)
( ) Pepdite Junior, Unflavored
( ) Pepdite Junior, Banana
In the future, because of the close medical supervision required with the use of an elemental formula, __________ (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 formula 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 Peptide Junior
Name |
Flavor |
Packaging |
Calories per Can |
Reimbursement/ NDC Code |
HCPCS Code |
| Pepdite Junior |
Unflavored
|
15 x 51 g (1.8 oz)
|
240 |
49735-0117-66
|
B4161 |
| Pepdite Junior |
Banana |
15 x 51 g (1.8 oz)
|
240 |
49735-0117-80
|
B4161 |
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