Sample Letter for
KetoCal 3:1 ^®

DATE:

TO: (Insurance Company)

FROM:

SUBJECT:

This is a request for insurance coverage and reimbursement for ___________________________________, a patient for whom I have prescribed KetoCal 3:1^® (manufactured by Nutricia North America).

KetoCal 3:1 is medically necessary and will provide appropriate dietary management for this patient, who has been diagnosed with __________________________________.  Seizures were occurring ____ times each day, despite attempts at seizure control with multiple drug therapy. Without the use of KetoCal 3:1, this individual may be unable to achieve seizure control causing an increase in hospitalizations and further drug interventions.

KetoCal 3:1 is a nutritionally complete, ketogenically balanced formula designed for individuals over the age of one year with intractable epilepsy, pyruvate dehydrogenase deficiency, or glucose transporter type-1 deficiency.  The macronutrient composition is set at a 3:1 ratio (fat: carbohydrate + protein), which has been clinically designed to induce and maintain ketosis, required for seizure control.

Two to three million Americans have epilepsy. Twenty to thirty percent of those individuals do not respond to drug therapy and are therefore classified as having intractable epilepsy.  The ketogenic diet is a proven effective therapy for people with seizures that are otherwise difficult to control.

The FDA classifies KetoCal 3:1 as a “medical food”, which must be used under strict medical supervision and is not sold over the counter or at the retail level.  KetoCal 3:1 is only available through a pharmacy or directly through Nutricia North America (with medical consent).  For a reimbursement code, please see the reverse side.

KetoCal 3:1 is considered an enteral anti-epileptic therapy rather than a nutritional supplement; therefore, we are requesting that KetoCal 3:1 be covered under your policies.  Your approval of this request for insurance coverage and reimbursement of KetoCal 3:1 would make a significant impact on this patient’s health.

Sincerely,

____________________________________

KETOCAL 3:1 AND REIMBURSEMENT

Third-party payers such as Medicaid and HMOs will reimburse for the cost of KetoCal 3:1.  To process claims for KetoCal 3:1, payers require a reimbursement code to identify the nutritional product/category.  Some states have enacted legislation, which require that reimbursement be provided based on the patient’s diagnosis.

Claims are usually processed in one of two ways.  A code is used to identify KetoCal 3:1 through the HCFA Healthcare Procedure Coding System (HCPCS), or through the National Drug Code (NDC) system.  Most states will use one of these systems to classify KetoCal 3:1 for reimbursement purposes.  Individual insurance plans will also choose one of these systems to reimburse patients for nutritional products.

CODING SYSTEMS:

MEDICARE (HCPCS)

KetoCal 3:1 is classified under Code # B4154.

NATIONAL DRUG CODE (NDC)

KetoCal 3:1 is not a drug but is classified by the FDA as a “medical food”, which requires usage under strict medical supervision.