<p>______Date: ______(Subscriber Name) ______(Subscriber ID Number) ______(Patient Name)</p><p>SUBJECT: Insurance Coverage Request for Neocate® Nutra</p><p>Dear Sir or Madam:</p><p>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). Based on this patient’s clinical history, I have determined that this amino acid-based, semi-solid product is medically necessary. </p><p>CHOOSE APPROPRIATE PARAGRAPH BASED ON PATIENT DEMOGRAPHICS AND/OR DIAGNOSIS: INFANTS 6+ Months: Neocate Nutra is a hypoallergenic, semi-solid medical food specifically designed to help meet nutritional needs of individuals with severe cow milk protein and/or multiple food protein allergies who are on very restricted diets and unable to tolerate intact proteins. When prepared, Neocate Nutra is the consistency of a soft cereal. As severe food allergies often result in a delayed introduction of solid foods at a time that serves as a critical milestone for oral motor skill development, Neocate Nutra allows patients with severe food allergies to safely explore new textures and appropriately develop oral motor skills with virtually no risk for an allergic reaction. Additionally, the elemental composition of Neocate Nutra is ideally suited for patients with compromised gastrointestinal function and food allergy-related symptoms. Neocate Nutra is also an excellent source of key nutrients for those on a food-restricted diet. BEYOND INFANCY/EoE: Neocate Nutra is a hypoallergenic, semi-solid medical food specifically designed to help meet nutritional needs of individuals with severe cow milk protein and/or multiple food protein allergies who are on very restricted diets and unable to tolerate intact proteins. Neocate Nutra allows individuals with severe food allergies to incorporate textures into the diet with virtually no risk for an allergic reaction. As severe food allergies often result in a diet limited to amino acid-based formulas, the elemental composition of Neocate Nutra makes it an ideal accompaniment to hypoallergenic formula-based diets, and is ideally suited for patients with compromised gastrointestinal function and food allergy-related symptoms. Neocate Nutra is an excellent source of key nutrients for those on restricted diets due to food allergy. Neocate Nutra is also used as the viscous delivery vehicle to administer topical medication to the esophagus in the management of eosinophilic esophagitis. </p><p>Neocate Nutra is medically necessary for my patient. Without the use of this amino acid-based semi-solid, my patient may experience more complications, such as nutritional deficiencies and/or problematic delays in the development of proper feeding skills, which may result in more severe feeding disorders later in life and/or the need to insert a feeding tube.</p><p>My patient NAME has been diagnosed with one or more of the following: Diagnosis ICD – 10 Code Page 1 of 3 □ bloody stool(s) K92.51 □ allergic gastroenteritis and colitis K52.2 *(add “Z” code signifying allergen – see last page) □ atopic dermatitis due to food allergy L27.2 □ allergic rhinitis due to food allergy J30.5 □ gastroesophageal reflux disease K21.9 □ malabsorption K90.9 □ short bowel syndrome K91.2 □ failure to thrive (newborn) P92.6 □ failure to thrive (non-newborn) R62.51 □ eosinophilic esophagitis K20.0 □ eosinophilic gastritis K52.81 □ eosinophilic gastroenteritis K52.81 □ eosinophilic colitis K52.82 □ underweight R63.6 *(add “Z” code for weight percentile – see last page)</p><p>My patient’s present weight is WEIGHT (kg) and length/height is LENGTH/HEIGHT (cm). This patient will require CALORIES kcal per day from Neocate Nutra. This amount may be adjusted as his/her nutritional needs change. </p><p>Neocate Nutra is not a drug, but the FDA classifies Neocate Nutra as a “Medical Food” which must be used under medical supervision. Most pharmacies and homecare suppliers have policies that require a prescription to purchase Neocate Nutra. A prescription helps assure the appropriate product is being dispensed and the patient is receiving medical supervision. </p><p>Your approval of this request for assistance with medical care and reimbursement of this medical food would have a significant positive impact on this patient’s health. This patient’s clinical nutritional status will be monitored by a gastroenterologist, pediatrician, registered dietitian and feeding specialist (EDIT AS APPROPRIATE).</p><p>Sincerely,</p><p>______Signature</p><p>______Name </p><p>______Title</p><p>______Title – Center/Hospital/Institution/Practice</p><p>Enclosures: Current Growth Chart, Letter of Dictation, Reports, Prescription</p><p>Page 2 of 3 Product and Reimbursement Information for Neocate Nutra Product Calories Reimbursement Name Packaging Flavor HCPCS Code Code per Can Code* Neocate Nutra 66739 4 x 400 g (14.1 oz) 1888 Unflavored 49735-0167-39 B4161 *Reimbursement codes listed here have been submitted by Nutricia North America to US data warehouses based on the format established by the data warehouses. These codes are not NDC (National Drug Code) numbers.</p><p>ICD-10 Codes and corresponding Z codes ICD-10 Code Z codes Allergy to milk products Z91.011 Allergic Gastroenteritis/Colitis K52.2 Allergy to other food Z91.018 Other non-medicinal substance allergy Z91.048 < 5th percentile Z68.51 5th percentile to < 85th percentile Z68.52 Underweight R63.6 85th percentile to 95th percentile Z68.53 ≥ 95th percentile for age Z68.54</p><p>Page 3 of 3</p>