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LETTER OF MEDICAL NECESSITY TEMPLATE: VITAFLO FRUITVITS (IEM)
DATE:
TO:
FROM:
PATIENT NAME:
ICD DIAGNOSIS CODE:
MEDICAL FOOD ORDER:
INSURANCE ID:
SUBSCRIBER:
DOB:
Ht:
Wt:
GROUP NO:
To Whom It May Concern:
[Patient name] is a _______ year old patient diagnosed with [disorder], an inborn error of metabolism. This patient’s
metabolic disease was diagnosed through newborn screening (if applicable) which is mandated by law in the USA. The
purpose of this letter is to explain the medical necessity of FruitiVits and request insurance coverage for this treatment.
[Disorder] is an inherited metabolic disease whereby the affected individual is unable to [describe pathophysiology].
The standard of care is to follow a restrictive therapeutic diet that eliminates or restricts [describe treatment
protocol]. As a result, the diet alone does not contain adequate vitamins, minerals and trace elements to meet the
daily requirements for these nutrients. Reports of vitamin and mineral deficiencies are well documented in the
scientific literature (1-5). To ensure nutritional adequacy of the diet, a multivitamin/mineral that is very low in
[carbohydrate/ lactose/ fructose and/or sucrose/ free (as applicable)] is required to meet these specific nutrient
needs.
In this patient’s case, I have specifically noted [lab values, evidence of vitamin, mineral or trace element
deficiency and/or inadequate intake]. I have prescribed FruitiVits to meet [Patient’s name] requirements for
essential nutrients and prevent deficiencies and the need for subsequent interventions. This prescribed medical food
is imperative in the treatment of this patient’s condition. FruitiVits is medically necessary to ensure that [he/she] meets
these specific nutrient needs.
FruitiVits, a medical food, is a flavored, powdered mix of vitamins, minerals and trace elements low in carbohydrate
(0.5 gm/packet), and lactose, fructose and sucrose free. It can be used orally or given via a bolus enteral/tube.
FruitiVits is manufactured in the UK for Vitaflo USA, LLC (1-888-848-2356.) HCPCS: B4014 Reimbursement Code:
NDC: 50600-0553-85 for 30 packets (6 g ea.) /box. FruitiVits is a medical food available ONLY by prescription (not
“over the counter”) to be used under strict medical supervision.
I appreciate your consideration of this request. Your authorization of this prescribed order will provide this patient the
treatment needed to improve his/her medical condition.
Please feel free to contact me if you have additional questions.
Sincerely,
Name of Physician
Institution
Contact Information
Attachments: Prescription
Clinic Notes
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4.
5.
Bodley et al (1993). Low iron stores in infants and children with treated phenylketonuria: A population at risk for iron-deficiency anaemia and associated
cognitive deficits. Eur Pediatr. 152:140-143.
Gropper et al (1998). Trace element status of children with PKU and normal children. J Am Diet Ass. 88: 459-464.
Acosta et al (1982). Zinc status and growth of children undergoing treatment for phenylketonuria. J Inher Met Dis 5: 107-110.
Yannicelli (1992). Decreased selenium intake and low plasma selenium concentrations leading to clinical symptoms in a child with propionic acidaemia. J
Inher Met Dis 15: 261-268.
Robert et al (2013) Micronutrient status in Phenylketonuria. Mol Gen Metab. 110: S6-S17.