Download New Mexico Medicaid Utilization Review Medical Justification for

New Mexico Medicaid Utilization Review
P.O. Box 27950 Albuquerque, NM 87125-7950
Medical Justification for Nutritional
Supplementation
Date:
Recipient:
Medicaid #:
Background: Effective 07/01/2004, NM Medicaid Regulations 8.324.5.12.A(2) NMAC specify that
NM Medicaid will only cover nutritional products in two circumstances: specially formulated medical
foods that are prescribed to treat inborn errors of metabolism* or internal (not oral) nutritional products
that are delivered by a feeding tube.
Circle One
1. Will the requested nutritional product be delivered by a feeding tube? If
yes, please provide the diagnosis or the clinical condition that has led to the
need for tube-feeding.
Y
N
Y
N
2. How long do you estimate the patient will need a feeding tube?
3. Does the patient have a recognized inborn error of metabolism? If yes,
please provide the specific inborn error of metabolism diagnosis.
*Note: Inborn errors of metabolism refers to inborn errors of amino acid metabolism, such as phenylketonuria,
maternal phenylketonuria, maple syrup urine disease, homocystinuria, methylmalonicacidemia,
propionicacidemia, isovalericacidemia, and other disorders of leucine metabolism; glutaricaciduria type I and
tyrosinemia types I and II; and urea cycle disorders. These disorders are treatable by dietary modifications,
which can prevent complications like severe mental retardation and death. Other metabolic disorders, including
those of carbohydrate and lipid metabolism would be eligible for coverage of special oral nutritional
supplements if the medical literature establishes the value of specific dietary interventions.
M.D. Signature:
MedJust-Nutrition Supp.doc