DATE:		_______________________________

TO:		_______________________________
                                                             (Insurance Company)
FROM:	_______________________________

SUBJECT:	_______________________________

I am requesting insurance coverage and reimbursement for my patient, ___________________________________, for whom I have prescribed the use of EO28 Splash (manufactured by Nutricia North America).

I feel that EO28 Splash is a medical necessity and will provide the proper dietary management for this patient, who has been diagnosed with __________________________________.  Without the use of EO28 Splash, my patient may experience complications of the condition, which may result in hospitalization and/or costly parenteral nutrition.

EO28 Splash  is an amino acid based nutritionally complete elemental formula. It is specifically designed to meet the nutritional needs of one to ten year olds who are unable to ingest a normal diet or other hypoallergenic products. Its unique formulation (100% free amino acids, milk free, gluten free, and soy protein free) provides complete nutrition and can often be the sole source of nutrition. EO28 Splash has an elemental composition, which requires minimal digestion, thus ideally suited for patients with compromised gastrointestinal function.

The FDA classifies EO28 Splash as a “medical food” which must be used under medical supervision and is not sold over the counter or at the retail level.  Therefore, EO28 Splash is only available through a pharmacy or through Nutricia North America directly (with medical consent).  For additional reimbursement codes and information, please see the reverse side.

Your approval of this request for insurance coverage and reimbursement of the EO28 Splash would make a significant impact on this patient’s health.

Sincerely,

EO28 SPLASH AND REIMBURSEMENT

Third-party payers such as Medicaid and HMOs will reimburse for the cost of EO28 Splash.  To process claims for EO28 Splash, payers require a reimbursement code to identify the nutritional product/category.  Some states have enacted legislation, which require that reimbursement be provided based on the patient’s diagnosis.

Claims are usually processed in one of two ways.  A code is used to identify EO28 Splash through the HCFA Healthcare Procedure Coding System (HCPCS), or through the National Drug Code (NDC) system.  Most states will use one of these systems to classify EO28 Splash for reimbursement purposes.  Individual insurance plans will also choose one of these systems to reimburse patients for nutritional products.

CODING SYSTEMS:

MEDICARE (HCPCS)

EO28 Splash is classified under Code # B4161.

NATIONAL DRUG CODE (NDC)

EO28 Splash is not a drug but is classified by the FDA as a “medical food”, which requires usage under strict medical supervision.  The NDC code for the EO28 Splash is:

	49735-0126-70		EO28 Splash, grape flavored
	49735-0126-66		EO28 Splash, tropical fruit flavored
	49735-0110-50		EO28 Splash, orange-pineapple flavored