Download Ulcerative Colitis

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Re: NDC/NHRIC format code: 69355-0516-01
Visbiome Extra Strength
Re: Name of Insurance Company
Address of Insurance
Patient name
DOB
Health plan and ID#
(Date)
To Whom It My Concern,
I am writing to request Visbiome Extra Strength for my patient, (name), who has been
diagnosed with Ulcerative Colitis, (ICD-9 556.0 – 556.9) (ICD-10 K51.8 – K52.1).
Visbiome Extra Strength is a prescription, high potency probiotic used for the dietary
management of Ulcerative Colitis (UC) and is medically necessary for the treatment of my
patient. I am recommending a dose of ____ packets daily for ____ days. One packet of
Visbiome Extra Strength contains 900 billion probiotic bacteria.
Ulcerative colitis is a chronic inflammatory bowel disease (IBD) that causes ongoing
inflammation and ulcers in the large intestine and rectum. Patients with Ulcerative Colitis are at
increased risk for malnutrition along with a number of other conditions such as arthritis, liver
disease, blood clots, and gallstones. If not properly treated, patients with UC can develop life
threatening conditions such as: perforation of the colon, abscess in the colon, toxic megacolon,
and colon cancer.
Visbiome Extra Strength is specially formulated and processed to provide a precise mixture of
certain bacterial species to the gastrointestinal tract. The gastrointestinal microflora, or
“microbiome”, is important for the normal functioning of the human gastrointestinal tract.
Patients with UC have documented deficiencies in luminal concentrations of lactobacilli and
bifidobacteria compared with healthy individuals. UC patients, may benefit from the
consumption of high levels of probiotic bacteria to maintain an adequate and balanced
microflora. In these patients, sufficient adjustment of the microflora cannot be achieved solely
through modification of the normal diet.
Visbiome Extra Strength can significantly reduce the deterioration of his/her medical condition
and will assist my patient to achieve or maintain maximum functional capacity in performing
daily activities that are appropriate for her/his condition and age.
Please let me know if you require additional information from my records.
Sincerely,