SAMPLE INSURANCE LETTER FOR
LOPROFIN^® FOODS

Date:
Company Name
Street Address
City, State Zip

RE: Patient Name

Dear Madam/Sir:

On behalf of my patient Patient's Name, I am submitting this letter to explain the medical condition for which I prescribed Loprofin food products.

Explain medical diagnosis and treatment.

Loprofin food products are specifically designed to be incorporated into the diet of individuals diagnosed with inborn errors of amino acid metabolism, such as phenylketonuria, maple syrup urine disease, and methylmalonic acidemia. Treatment for these patients consists of a special diet to be composed of an amino acid based formula and specially manufactured foods containing negligible amounts of protein. Both components are classified as medical foods which are defined as ".a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation"¹. Loprofin low protein breads, pasta, crackers, and cookies can be safely incorporated into the diet regime so that maximum growth potential can be achieved and mental retardation prevented. Loprofin products are prescribed and are medically necessary in this instance as the optimum treatment for Patient's Name with a diagnosis of Diagnosis.

I respectfully request insurance reimbursement/coverage for Loprofin products.

Sincerely,

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