Letter Med Nec Boost Kid Essentials 1 5 Fiber 0516

Letter of Medical Necessity

Date: Month, Day, Year

TO: Insurance Company FROM: Physician Name

SUBJECT: Request for coverage and/ reimbursement for BOOST® Kid Essentials™ 1.5 With Fiber nutritionally complete drink.

I am requesting insurance coverage and reimbursement on behalf of my patient, Name/Date of Birth. I have prescribed BOOST® Kid Essentials™ 1.5 With Fiber nutritionally complete drink for the dietary management of Diagnosis or Condition.

Verify medical necessity for formula, including:  Date of birth  Diagnosis  Height  Weight  Weight history  Tracking on growth chart  Brief documentation of weight loss/intolerance  Nutrition prescription

BOOST® Kid Essentials™ 1.5 With Fiber is a nutritionally complete drink with 1.5 kcals/mL and 2g fiber per serving for children 1 – 13 years of age. This product is intended for the nutritional management of patients with:  Inadequate oral intake  Increased energy needs  Volume intolerance  Malnutrition  Bowel management needs

BOOST® Kid Essentials™ 1.5 With Fiber is a nutritionally complete drink that delivers 50% more calories per serving than standard 1.0 kcal/mL formulas, for children 1-13 years of age. It contains 2 grams of fiber per serving to help support digestive health and normal bowel function, and can be used for tube feeding or oral supplementation. The formula is recognized by the Centers for Medicare and Medicaid Services (CMS) as “an enteral formula for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/mL) with intact nutrients; includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube”, found in HCPCS Category B4160. 1 Name Flavor Case UPC Packaging Calories Reimbursement/NDC HCPCS per Formatted Number Code Carton BOOST® Kid Very 10043900335008 27 – 8 fl oz 360 43900-0335-00 B4160 Essentials™ Vanilla cartons/case 1.5 With Fiber

Thank you for taking the time to review this request. Please contact me should you require any additional information.

Sincerely,

Signature: Name: Title:

Attachments: You may want to include pertinent information supporting evidence of medical necessity and product information. Please refer to www.NestleHealthScience.us for product information.