___________________________
Date: ________________
(Subscriber Name)
___________________________
(Subscriber ID Number)
___________________________
(Patient Name)
SUBJECT: Insurance Coverage Request for Neocate® Splash
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 Neocate® Splash, a ready-to-feed, amino acid-based formula (manufactured by SHS International, distributed by Nutricia
North America). Based on this patient’s clinical history, I have determined that this formula is medically necessary.
My patient’s present weight is WEIGHT (kg) and height is HEIGHT (cm). He/She will require CALORIES kcal per day or FLUID
OUNCES fl oz per day of Neocate Splash. This amount may be adjusted as his/her nutritional needs change. The unique
formulations of Neocate Splash products (based on 100% free, non-allergenic amino acids) provide supplemental or complete
nutrition and may be the primary or sole source of nutrition for this patient. Presently, Neocate Splash will be taken:
( ) by Feeding Tube
( ) Orally – However, if unable to consume enough formula to meet the nutritional requirements for proper growth
and development, we may consider alternate feeding methods, such as insertion of a feeding tube.
To date, my patient has failed to tolerate cow milk- and soy-based and/or protein hydrolysate formulas. Neocate Splash is
specifically designed to meet the nutritional needs of patients with severe cow milk protein or multiple food protein allergies
who are unable to tolerate nutritional products containing intact protein or hydrolyzed protein. Some products containing
hydrolyzed protein may be considered hypoallergenic, but they contain cow milk protein, which my patient does not tolerate.
The amino acid composition of Neocate Splash, which requires minimal digestion and is 100% dairy free, is ideally suited for
patients with compromised gastrointestinal function and/or food allergy-related symptoms. The amount needed per day of
Neocate Splash depends on the age, body weight, and medical condition, as prescribed by myself.
Neocate Splash is medically necessary for my patient, and will provide the proper medical nutrition management for this patient.
Without the use of an amino acid-based formula, my patient may experience more complications, which can result in
hospitalizations and/or costly parenteral nutrition.
My patient NAME has been diagnosed with one or more of the following:
Diagnosis
□ bloody stool(s)
□ allergic gastroenteritis and colitis
□ atopic dermatitis due to food allergy
□ allergic rhinitis due to food allergy
□ gastroesophageal reflux disease
ICD – 10 Code
K92.1
K52.2 *(add “Z” code signifying allergen – see last page)
L27.2
J30.5
K21.9
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□ malabsorption
□ short bowel syndrome
□ failure to thrive (newborn)
□ failure to thrive (non-newborn)
□ eosinophilic esophagitis
□ eosinophilic gastritis or gastroenteritis
□ eosinophilic colitis
□ underweight
K90.9
K91.2
P92.6
R62.51
K20.0
K52.81
K52.82
R63.6 *(add “Z” code for weight percentile – see last page)
Neocate Splash is not a drug, but the FDA classifies Neocate Splash 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 Splash. A
prescription helps assure the appropriate product is being dispensed and the patient is receiving medical supervision.
For the above-outlined medical reasons, I am prescribing the following:
(Please see last page for the product and reimbursement codes)
( ) Neocate Splash, Unflavored
( ) Neocate E028 Splash: Grape, Tropical Fruit, Orange-Pineapple Circle flavor(s)
In the future, because of the close medical supervision required with the use of an amino acid-based formula, NAME will need
active and ongoing medical supervision to observe his/her growth and development and evaluate his/her nutritional
requirements. This patient’s clinical nutritional status will be monitored by a gastroenterologist, pediatrician, registered dietitian
and feeding specialist (EDIT AS APPROPRIATE).
Your approval of this request for assistance with medical care and reimbursement of the formula would have a significant
positive impact on this patient’s health.
Sincerely,
______________________________________________
Signature
______________________________________________
Name
______________________________________________
Title
______________________________________________
Title – Center/Hospital/Institution/Practice
Enclosures: Current Growth Chart, Letter of Dictation, Reports, Prescription
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Product and Reimbursement Information for Neocate Splash
Name
Flavor
Product
Code
Packaging
Calories
per Box
Reimbursement Code*
HCPCS
Code
Neocate Splash,
Unflavored
Unflavored
84451
27 x 237 mL (8 fl oz)
237
49735-0144-51
B4161
Neocate E028
Splash
Grape
12670
27 x 237 mL (8 fl oz)
237
49735-0126-70
B4161
Neocate E028
Splash
Tropical
Fruit
12666
27 x 237 mL (8 fl oz)
237
49735-0126-66
B4161
Neocate E028
Splash
OrangePineapple
11050
27 x 237 mL (8 fl oz)
237
49735-0110-50
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.
ICD-10 Codes and corresponding Z codes
ICD-10 Code
Z codes
Allergic Gastroenteritis/Colitis
K52.2
Underweight
R63.6
Allergy to milk products
Z91.011
Allergy to other food
Z91.018
Other non-medicinal substance allergy Z91.048
< 5th percentile
Z68.51
5th percentile to < 85th percentile
Z68.52
85th percentile to 95th percentile
Z68.53
≥ 95th percentile for age
Z68.54
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