Dear Insurance Coordinator, This patient, _____________________________ has significant impairment of fat metabolism resulting in malabsorption of dietary fat and various essential vitamins. Of particular concern is the malabsorption and resulting deficiency of vitamin E, which contributes to progressive neurological deterioration, muscle weakness, and other adverse effects. Supplementation with complete vitamin E is necessary to avoid these neurological consequences and potential morbidities. Due to the significant impairment of fat metabolism, supplementation with standard vitamin E failed to normalize blood levels and the patient failed to achieve adequate nutritional status utilizing other supplements. It is also necessary for the patient to receive the complete family of tocopherols and tocotrienols and not alpha-tocopherol alone. This patient needs to be supplemented with Aqua-E, a specially formulated, water soluble form of the natural and complete vitamin E that was clinically tested in a malabsorbing population and shown to increase absorption over vitamin E softgels. I have recommended that this patient supplement with Aqua-E at the dose of ____mL per day, and he/she is therefore requesting insurance coverage for this medically necessary supplement. Sincerely, __________________________________ Treating Physician __________________________________ Treating Dietitian Supporting Clinical Papas K, Kalbfleisch J, Mohon R. Bioavailability of a novel, water-soluble vitamin E formulation in malabsorbing patients. Dig Dis Sci. 2007 Feb;52(2):347-52
Dear Insurance Coordinator, This patient, _____________________________ has significant impairment of fat metabolism resulting in malabsorption of dietary fat and various essential vitamins. Of particular concern is the malabsorption and resulting deficiency of vitamin E, which contributes to progressive neurological deterioration, muscle weakness, and other adverse effects. Supplementation with complete vitamin E is necessary to avoid these neurological consequences and potential morbidities. Due to the significant impairment of fat metabolism, supplementation with standard vitamin E failed to normalize blood levels and the patient failed to achieve adequate nutritional status utilizing other supplements. It is also necessary for the patient to receive the complete family of tocopherols and tocotrienols and not alpha-tocopherol alone. This patient needs to be supplemented with Aqua-E, a specially formulated, water soluble form of the natural and complete vitamin E that was clinically tested in a malabsorbing population and shown to increase absorption over vitamin E softgels. I have recommended that this patient supplement with Aqua-E at the dose of ____mL per day, and he/she is therefore requesting insurance coverage for this medically necessary supplement. Sincerely, __________________________________ Treating Physician __________________________________ Treating Dietitian Supporting Clinical Papas K, Kalbfleisch J, Mohon R. Bioavailability of a novel, water-soluble vitamin E formulation in malabsorbing patients. Dig Dis Sci. 2007 Feb;52(2):347-52
Aqua-E-medical-necessity-letter.docx