SAMPLE LETTER FOR
COMPLETE AMINO ACID MODULE #10124

Date
Company Name
Street Address
City, State and Zip

RE: Patient Name

Dear Sir or Madam:

On behalf of my patient, Patient's name, I am submitting this letter to explain the medical condition for which I prescribe Complete Amino Acid Module #10124.

Explain medical diagnosis and treatment.

Complete Amino Acid Module is indicated where a nutritionally complete feeding is not suitable and a modular approach to formula feeding is required. The Complete Amino Acid Module is used when a hypoallergenic diet is indicated (i.e. patients with severe cow milk protein allergy or other whole protein allergy) and the patient has failed to tolerate other hypoallergenic formulas. It is also appropriate for patients with intractable malabsorption, feeding difficulties in post-operative conditions, chronic intestinal diseases, and Short Bowel Syndrome. The Complete Amino Acid Module is the only protein module available in the form of free amino acids. The protein content is modeled after a high biological value protein, in that it contains both essential and nonessential free amino acids. The product's elemental protein composition requires minimal digestion, thus ideally suited for patients with compromised gastrointestinal function.

Complete Amino Acid Module #10124 is prescribed and is medically necessary in this instance as the optimum treatment for Patients Name with a diagnosis of Diagnosis. I respectfully request insurance reimbursement/coverage for Complete Amino Acid Module #10124. 

The reimbursement code for this product is 49735010124.

Sincerely,

Physician's Signature
Physician's Name
Physician's Address