LETTER OF MEDICAL NECESSITY
LETTER OF MEDICAL NECESSITY TEMPLATE: Vitaflo MCT ProcalDATE:TO:FROM:PATIENT NAME: DOB:ICD DIAGNOSIS CODE: Ht: Wt:MEDICAL FOOD ORDER: INSURANCE ID:SUBSCRIBER:GROUP NO:To Whom It May Concern:[Patient Name] is a____year old patient diagnosed with [VLCAD/LCHAD], a long chain fatty acid oxidation disorder (LCFAOD), an inborn error of metabolism. This patient’s metabolic disease was diagnosed [through newborn screening (if applicable) which is mandated by law in the USA] on [date]. The purpose of this letter is to explain the medical necessity of Vitaflo MCT Procal and request insurance coverage for this treatment.[Disease] is a life-long inherited metabolic disease whereby the affected individual is unable to metabolize long chain fatty acids (LCFA), which are highly prevalent in a regular, unrestricted diet. This is a result of defects in the enzymes needed to convert LCFAs to shorter fatty acids, which are then used as energy by the body. Medium chain fats bypass the enzymes that are blocked in long chain fatty acid oxidation disorders, and they are used as an alternative source of fat. The accepted standard of care is to reduce total fat intake, limiting LCFA while replacing with MCT, to ensure adequate energy intake to meet individual calorie requirements. [Patient name] is currently prescribed MCT Procal, a powdered medical food containing high MCT and low LCFA and formulated to meet the specific needs of patients fed orally or enterally with [disease]. The prescribed medical food is imperative in the treatment of this patient’s condition. Without this specific treatment, the patient will develop a toxic buildup of fatty acids in the liver and other tissues. If the patient is not treated accordingly, immediate medical consequences ensue, including [hypoglycemia, metabolic crisis, coma, death, other]. [He/She] will develop [poor growth, liver abnormalities, cardiomyopathy, rhabdomyolysis, retinopothy, vision loss, seizure, coma, other]. In [patient name’s] case I have specifically noted [labs, symptoms, other abnormalities]. MCT Procal is medically necessary to ensure that [patient name] maintains metabolic control. MCT Procal is manufactured in the UK for Vitaflo USA, LLC (1-888-848-2356.) HCPCS: B4155. Reimbursement Code: 50600-0502-36 (30 packets/box) or 50600-0507-62 (tub). Vitaflo MCT Procal is a medical food available ONLY by prescription (not “over the counter”) to be used under strict medical supervision.[If applicable: In addition, MCT Procal is on the State of _____ Medicaid, BCMH, and/or Metabolic Formulary] 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. Please feel free to contact me if you have additional questions.Sincerely, Name of PhysicianInstitutionContact InformationAttachments: Prescription Clinic Notes ................
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