Letter of Medical Necessity

Date: Month, Day, Year

TO: Insurance Company

FROM: Physician Name

SUBJECT: Request for coverage and/ reimbursement for BOOST® Kid Essentials™ 1.5 nutritionally complete drink.

I am requesting insurance coverage and reimbursement on behalf of my patient, Name/Date of Birth. I have prescribed BOOST® Kid Essentials™ 1.5 nutritionally complete drink for the dietary management of Diagnosis or Condition.

Verify medical necessity for formula, including:

·  Date of birth

·  Diagnosis

·  Height

·  Weight

·  Weight history

·  Tracking on growth chart

·  Brief documentation of weight loss/intolerance

·  Nutrition prescription

BOOST® Kid Essentials™ 1.5 is a nutritionally complete drink with 1.5 kcals/mL for children 1 – 13 years of age. This product is intended for the nutritional management of patients with:

·  Inadequate oral intake

·  Increased energy needs

·  Volume intolerance

·  Malnutrition

BOOST® Kid Essentials™ 1.5 is a nutritionally complete drink that delivers 50% more calories per serving than standard 1.0 kcal/mL formulas, for children 1-13 years of age. It is available in 3 flavors (very vanilla, rich chocolate and creamy strawberry) and can be used for tube feeding or oral supplementation. The formula is recognized by the Centers for Medicare and Medicaid Services (CMS) as “an enteral formula for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/mL) with intact nutrients; includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube”, found in HCPCS Category B4160.

Name / Flavor / Case UPC / Packaging / Calories per Carton / Remimbursement/NDC
Formatted Number / HCPCS Code
BOOST® Kid Essentials™ 1.5 / Very Vanilla / 10043900335442 / 27 – 8 fl oz cartons/case / 360 / 43900-0335-40 / B4160
BOOST® Kid Essentials™ 1.5 / Rich Chocolate / 10043900335886 / 27 – 8 fl oz cartons/case / 360 / 43900-0335-88 / B4160
BOOST® Kid Essentials™ 1.5 / Creamy Strawberry / 10043900335992 / 27 – 8 fl oz cartons/case / 360 / 43900-0335-90 / B4160

Thank you for taking the time to review this request. Please contact me should you require any additional information.

Sincerely,

Signature:

Name:

Title:

Attachments: You may want to include pertinent information supporting evidence of medical necessity and product information. Please refer to www.NestleHealthScience.us for product information.

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