___________________________
Date: ________________
(Subscriber Name)
___________________________
(Subscriber ID Number)
___________________________
(Patient Name)
SUBJECT: Insurance Coverage Request for Neocate® Nutra
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® 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.
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 amino acid 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 amino acid
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.
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.
My patient NAME has been diagnosed with one or more of the following:
Page 1 of 3
Diagnosis
ICD – 10 Code
□ bloody stool(s)
□ allergic gastroenteritis and colitis
□ atopic dermatitis due to food allergy
□ allergic rhinitis due to food allergy
□ gastroesophageal reflux disease
□ malabsorption
□ short bowel syndrome
□ failure to thrive (newborn)
□ failure to thrive (non-newborn)
□ eosinophilic esophagitis
□ eosinophilic gastritis or gastroenteritis
□ eosinophilic colitis
□ underweight
K92.1
K52.2 *(add “Z” code signifying allergen – see last page)
L27.2
J30.5
K21.9
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)
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.
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.
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).
Sincerely,
______________________________________________
Signature
______________________________________________
Name
______________________________________________
Title
______________________________________________
Title – Center/Hospital/Institution/Practice
Enclosures: Current Growth Chart, Letter of Dictation, Reports, Prescription
Page 2 of 3
Product and Reimbursement Information for Neocate Nutra
Name
Product
Code
Packaging
Calories
per Can
Flavor
Reimbursement
Code*
HCPCS 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.
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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