Download Date: (Subscriber Name) (Subscriber ID Number) (Patient Name

___________________________
Date: ________________
(Subscriber Name)
___________________________
(Subscriber ID Number)
___________________________
(Patient Name)
SUBJECT: Insurance Coverage Request for Pepdite® Junior
Dear Sir or Madam:
I am requesting insurance coverage and reimbursement for my patient, NAME, born on D.O.B., for whom I have prescribed the
use of Pepdite® Junior formula (manufactured by SHS International, distributed by Nutricia North America). Based on this
patient’s clinical history, I have determined that this formula is medically necessary.
My patient’s present weight is WEIGHT (kg) and height is HEIGHT (cm). He/She will require CALORIES kcal per day or FLUID
OUNCES fl oz per day of Pepdite Junior. This amount may be adjusted as his/her nutritional needs change. Pepdite Junior is a
unique, non-dairy hydrolysate based on 44% non-allergenic amino acids and 56% low molecular weight peptides for individuals
over the age of 1 year. Pepdite Junior provides complete nutrition and may be the sole source of nutrition for this patient.
Presently, Pepdite Junior will be taken orally, however if he/she is unable to consume enough formula to meet the nutritional
requirements for proper growth and development, we may consider alternate feeding methods, such as insertion of a feeding
tube.
To date, my patient has failed to tolerate cow milk-based and cow milk hydrolysate formulas. Pepdite Junior is specifically
designed to meet the nutritional needs of patients with severe cow milk protein or multiple food protein allergies who are
unable to tolerate nutritional products containing intact protein. The composition of Pepdite Junior, which requires minimal
digestion and is 100% dairy free, is ideally suited for patients with compromised gastrointestinal function and/or dairy allergyrelated symptoms. The formula concentration depends on the age, body weight, and medical condition, as prescribed by myself.
Pepdite Junior is medically necessary for my patient, and will provide the proper medical nutrition management for this patient.
Without the use of Pepdite Junior, my patient may experience more complications, which can result in hospitalizations and/or
costly parenteral nutrition.
My patient NAME has been diagnosed with one or more of the following:
Diagnosis
□ bloody stool(s)
□ allergic gastroenteritis and colitis
□ atopic dermatitis due to food allergy
□ allergic rhinitis due to food allergy
□ gastroesophageal reflux disease
□ malabsorption
□ short bowel syndrome
□ failure to thrive (newborn)
ICD – 9 Code
578.1
558.3 *(add “v” code signifying allergen – see last page)
693.1
477.1
530.81
579.9
579.3
779.34
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□ failure to thrive (non-newborn)
□ eosinophilic esophagitis
□ eosinophilic gastritis
□ eosinophilic gastroenteritis
□ eosinophilic colitis
□ underweight
783.41
530.13
535.7
558.41
558.42
783.22 *(add “v” code for weight percentile – see last page)
Pepdite Junior is not a drug, but the FDA classifies Pepdite Junior as a “Medical Food” which must be used under medical
supervision. Most pharmacies and homecare suppliers have policies that require a prescription to purchase Pepdite Junior. A
prescription helps assure the appropriate product is being dispensed and the patient is receiving medical supervision.
In the future, because of the close medical supervision required with the use of a medical food, NAME will need active and
ongoing medical supervision to observe his/her growth and development and evaluate his/her nutritional requirements. This
patient’s clinical nutritional status will be monitored by a gastroenterologist, pediatrician, registered dietitian and feeding
specialist (EDIT AS APPROPRIATE).
Your approval of this request for assistance with medical care and reimbursement of the formula would have a significant
positive impact on this patient’s health.
Sincerely,
______________________________________________
Signature
______________________________________________
Name
______________________________________________
Title
______________________________________________
Title – Center/Hospital/Institution/Practice
Enclosures: Current Growth Chart, Letter of Dictation, Reports, Prescription
Page 2 of 3
Product and Reimbursement Information for Pepdite Junior
Name
Flavor
Product
Code
Packaging
Calories
per Sachet
Yield per
sachet*
Reimbursement
Code†
HCPCS
Code
Pepdite Junior
Unflavored
11766
15 x 51 g (1.8 oz)
240
8 fl oz
49735-0117-66
B4161
*At standard dilution of 30 kcal/fl oz.
†Reimbursement codes listed here have been submitted by Nutricia North America to US data warehouses based on the format established by
the data warehouses. These codes are not NDC (National Drug Code) numbers.
ICD-9 Codes and corresponding V codes
ICD-9 Code
V codes
Allergic Gastroenteritis/Colitis
558.3
Underweight
783.22
Allergy to milk products
Allergy to eggs
Other Food Allergies
< 5th percentile
5th percentile to < 85th percentile
85th percentile to 95th percentile
≥ 95th percentile for age
V15.02
V15.05
V15.09
V85.51
V85.52
V85.53
V85.54
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