Letter of Medical Necessity Date: Month, Day, Year TO: Insurance Company FROM: Physician Name SUBJECT: Request for coverage/ reimbursement for Junior Alfamino™ Infant or Alfamino™ hypoallergenic amino acid-based formula I am requesting insurance coverage and reimbursement on behalf of my patient, Name/Date of I have prescribed Infant or Junior hypoallergenic amino Birth. Alfamino™ Alfamino™ formula, manufactured by Nestlé HealthCare Nutrition Inc. for the dietary management of Diagnosis or Condition. Verify medical necessity for formula, including: diagnosis, documented failure or intolerance to other formulas, current HT/WT/IBW, history of weight loss, pertinent lab results, medications, potential outcome if formula were denied. Infant is classified as an exempt infant formula and Junior as a medical Alfamino™ Alfamino™ food. Both products must be used under medical supervision, and are only available through a pharmacy, home care company or Nestlé directly (with medical consent). Infant (for infants age 0-12 months) and Junior (for children ages 1-13 Alfamino™ Alfamino™ years) are both nutritionally complete, hypoallergenic amino acid-based formulas. These formulas are appropriate for infants/children with the following conditions: cow’s milk protein allergy, multiple food allergies, eosinophilic GI disorders, malabsorptive conditions, short bowel syndrome or other conditions in which an amino acid-based diet would be beneficial (such as transition from TPN or early enteral feeding). Without the use of my patient may experience Alfamino™ Infant/Alfamino™ Junior, symptoms. Your approval of this request for insurance coverage and reimbursement of the Alfamino™ Junior would make a significant impact on the nutritional management of this Infant/Alfamino™ patient. Product Information for Infant and Junior Alfamino™ Alfamino™
Letter of Medical Necessity Date: Month, Day, Year TO: Insurance Company FROM: Physician Name SUBJECT: Request for coverage/ reimbursement for Alfamino™ Infant or Alfamino™ Junior hypoallergenic amino acid-based formula I am requesting insurance coverage and reimbursement on behalf of my patient, Name/Date of Birth. I have prescribed Alfamino™ Infant or Alfamino™ Junior hypoallergenic amino formula, manufactured by Nestlé HealthCare Nutrition Inc. for the dietary management of Diagnosis or Condition. Verify medical necessity for formula, including: diagnosis, documented failure or intolerance to other formulas, current HT/WT/IBW, history of weight loss, pertinent lab results, medications, potential outcome if formula were denied. Alfamino™ Infant is classified as an exempt infant formula and Alfamino™ Junior as a medical food. Both products must be used under medical supervision, and are only available through a pharmacy, home care company or Nestlé directly (with medical consent). Alfamino™ Infant (for infants age 0-12 months) and Alfamino™ Junior (for children ages 1-13 years) are both nutritionally complete, hypoallergenic amino acid-based formulas. These formulas are appropriate for infants/children with the following conditions: cow’s milk protein allergy, multiple food allergies, eosinophilic GI disorders, malabsorptive conditions, short bowel syndrome or other conditions in which an amino acid-based diet would be beneficial (such as transition from TPN or early enteral feeding). Without the use of Alfamino™ Infant/Alfamino™ Junior, my patient may experience symptoms. Your approval of this request for insurance coverage and reimbursement of the Alfamino™ Infant/Alfamino™ Junior would make a significant impact on the nutritional management of this patient. Product Information for Alfamino™ Infant and Alfamino™ Junior