EO28 Splash - Sample Insurance Letter
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Sample Insurance Letter for
E028 Splash®
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 E028 Splash® formula (manufactured by SHS International, distributed by Nutricia North America).
E028 Splash is specifically designed to meet the nutritional needs of children ages 1-10 with severe cow milk protein or multiple food protein allergies who are unable to ingest a normal diet or hydrolyzed nutritional products . Some of these hydrolyzed products may be considered hypoallergenic, but they contain cow's milk protein, which my patient does not tolerate. In fact, my patient has failed to tolerate cow's milk, soy based and/or protein hydrolysate formulas.
The unique formulation (100% free, non-allergenic amino acids) provides complete nutrition and may be the sole source of nutrition for this patient. The elemental composition, which requires minimal digestion, is ideally suited for patients with compromised gastrointestinal function and food-allergy related symptoms. Formula intake depends on the age, body weight, and medical condition of the patient and is prescribed by me.
E028 Splash formula is medically necessary for my patient, and will provide the proper nutrition for this patient. Without the use of this amino acid-based, truly elemental formula, my patient might experience more complications, which could result in hospitalization and/or costly parenteral nutrition.
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 ____(lenght) cm. He/She will require _____ (calories) kcal/_____ (ounces) ounces per day. This amount may be adjusted as his/her nutritional needs change.
Presently, E028 Splash will be taken orally, however if he/she is unable to consume enough formula to meet the nutritional requirement for proper growth and development, we may consider alternate feeding methods, such as a feeding tube.
Clinical trials have demonstrated the benefits, efficacy and safety of amino acid based formulas in children who do not tolerate extensively hydrolyzed formulas and/or whole protein. Amino acid based formulas promote normal growth and development for children who may otherwise experience failure to thrive. Amino acid-based formulas have also demonstrated resolution of symptoms within a short period of time.
E028 Splash is not a drug, but considered a medical food. As such, the product must be used under medical supervision and is not sold over the counter or at retail level. Therefore, E028 Splash has to be special ordered through a pharmacy or through Nutricia North America directly.
E028 Splash is medically necessary for this patient and I am prescribing the following: (Please see below for the product and reimbursement codes)
( ) E028 Splash, Grape
( ) E028 Splash, Tropical Fruit
( ) E028 Splash, Orange-Pineapple
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 E028 Splash
Name |
Flavor |
Packaging |
Calories per Can |
Reimbursement/ NDC Code |
HCPCS Code |
| E028 Splash |
Grape |
27 x 237 mL (8 fl oz) |
237 |
49735-0126-70
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B4161 |
| E028 Splash |
Tropical Fruit |
27 x 237 mL (8 fl oz) |
237 |
49735-0126-66 |
B4161 |
| E028 Splash |
Chocolate
Orange-Pineapple |
27 x 237 mL (8 fl oz) |
237 |
49735-0110-50 |
B4161 |
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