Letter of Medical Necessity s2

LETTER OF MEDICAL NECESSITY TEMPLATE: VITAFLO Betaquik (Ketogenic) DATE: TO: FROM: PATIENT NAME: DOB: ICD DIAGNOSIS CODE: Ht: Wt: MEDICAL FOOD ORDER: INSURANCE ID: SUBSCRIBER: GROUP NO:

To Whom It May Concern:

[Patient Name] is a [age] year old patient diagnosed with [disorder]. [Disorder] causes uncontrollable seizures [and list other related conditions if applicable]. Seizures were occurring ____ times each day, despite attempts at seizure control with drug therapy. Without the use of a ketogenic diet, including betaquik®, this individual may be unable to achieve seizure resulting in increased hospitalizations and further drug interventions. The purpose of this letter is to explain the medical necessity of betaquick, and request insurance coverage for this medical food.

The ketogenic diet is a proven effective therapy for people with seizures that are otherwise difficult to control. The ketogenic diet is a standard therapy used for the dietary management of intractable epilepsy. The diet is also suitable for certain disorders of carbohydrate metabolism, including Glucose Transporter Type 1 Deficiency (Glut-1 Deficiency) and Pyruvate Dehydrogenase Complex Deficiency (PDCD). This very restrictive high fat, low carbohydrate diet causes the body to burn fat rather than carbohydrate for energy. The metabolism of fat results in the production of ketones, which provide an alternative energy source to the brain. Medium chain triglycerides (MCT) are more “ketotic” than dietary fat, meaning they boost ketone production for patients on a ketogenic diet. MCT cannot be obtained in sufficient amounts from the diet alone, therefore betaquik is a necessary medical food.

Betaquik is a ready to use, liquid emulsion of medium chain triglycerides (MCT) for use in the ketogenic diet. betaquik is manufactured in the UK for Vitaflo USA, LLC (1-888-848-2356.) HCPCS: B4155 Reimbursement Code: 20600-0578-53 for 18x 250 ml /case. Betaquik is a medical food available ONLY by prescription (not “over the counter”) to be used under strict medical supervision.

I appreciate your consideration of this request. Your authorization of this prescribed order will provide this patient the treatment needed to improve his/her medical condition.

Please feel free to contact me if you have additional questions.

Sincerely, Name of Physician Institution Contact Information Attachments: Prescription Clinic Notes