LETTER OF MEDICAL NECESSITY TEMPLATE
DATE:
TO:
FROM:
PATIENT NAME:
ICD DIAGNOSIS CODE:
MEDICAL FOOD ORDER:
INSURANCE ID:
SUBSCRIBER:
DOB:
GROUP NO:
To Whom It May Concern:
NAME is a X- year old patient diagnosed with DISORDER/OTHER DISORDER, an inborn error of metabolism. The
purpose of this letter is to explain the medical necessity of NAME OF AMINO ACID ORDERED and request insurance
coverage for this treatment.
DISORDER is a rare genetic disorder whereby the affected individual is unable to _____________________. The
accepted standards of care to treat this disorder consist of _________________. Plasma levels of SPECIFIC AMINO
ACID are monitored routinely as a critical aspect of maintaining metabolic control of this disorder. When lab levels are
too low, precise adjustments are made in the corresponding amino acid dose to regain metabolic control thus
preventing NOTE SYMPTOMS/PROBLEMS and possible hospitalization. In addition, hospitalizations due to
metabolic instability can occur because a low level of SPECIFIC LAB and is associated with MEDICAL PROBLEM
and NOTE CRITICAL CONSEQUENCES.
In PT NAME’s situation I have noted (_____ labs up/down, symptoms). This product is imperative in the treatment of
this patient’s condition. The individual pre-measured amino acid dose which are in a heat and moisture stable packet,
ensure that this medical food is administered in the most accurate and reliable manner.
PRODUCT NAME is a powdered amino acid medical food which provides the amino acid to meet PATIENT NAME’s
specific needs to maintain metabolic control. It is manufactured in the UK and distributed by Vitaflo USA, LLC (1-888848-2356. HCPCS is XXXXXXX. Reimbursement code: XXXXXX. Vitaflo AMINO ACID NAME is a medical food that is
available ONLY by prescription (not “over the counter”) to be used under strict medical supervision.
IF APPLICABLE INCLUDE: In addition, PRODUCT NAME is a product that is on the State of XYZ’s
MEDICAID/BCMH/METABOLIC FORMULARY/IES.
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 situation, resulting in an overall cost savings to your company.
Please feel free to contact me if you have additional questions.
Sincerely,
Name of Physician
Institution
Contact Information