SAMPLE LETTER FOR MONOGEN ^®

Date: ________________

To: ___________________________
                (Insurance Company Name)
      ____________________________
                (Insurance Company Address)
      ____________________________
               (Insurance Company Address)

Dear Sir or Madam:

I am requesting insurance coverage and reimbursement for my patient, [Patient's Name], for whom I have prescribed the use of the Monogen (distributed by Nutricia North America).

Monogen is a medical food formula for the dietary management of long chain fatty acid oxidation disorders. These disorders are rare—long chain 3-OH acyl-CoA dehydrogenase deficiency, for example, is estimated to have an incidence of 1:50,000 to 1:200,000. Individuals with these disorders cannot metabolize long chain fatty acids (LCFA), a certain group of fats commonly found in fat-containing foods.  These disorders result from defects in enzymes needed to convert LCFAs to smaller fatty acids—a process necessary to produce energy in the body.

The main goals of dietary management are to reduce dietary long chain fatty acids and avoid fasting. Tolerance of dietary LCFA is individual and depends on the remaining activity of the blocked enzymes. The actual recommended amounts of restricted dietary LCFA and total fat may differ from clinic to clinic.  Typically, 10% or less of the daily required calories is needed and tolerated from LCFA. Recommendation of total fat intake may be reduced to as low as 25% of total energy intake.

In order to reach the goal of reduced total fat intake with limited LCFA and to provide adequate calories, medium chain fats (MCT) are used in formulas or directly added to the diet. Medium chain fats bypass the enzymes that are blocked in long chain fatty acid oxidation disorders, and they can be used as alternative sources of fat.

However, MCTs do not contain any of the long chain essential fatty acids needed by the body. Consequently, the amount and type of long chain fatty acids in the diet must be carefully considered to provide sufficient but not excessive amounts of these important fatty acids.

Monogen is an ideal formula for use in long chain fatty acid oxidation disorders. Here are some of the unique features and benefits of the product:

• Monogen provides 25% of calories from fat as recommended for a low fat diet
• Monogen has a high content of MCT (90% of fat is MCT), which bypasses the blocked enzymes
• In contrast to other formulas, Monogen offers a balanced ratio of essential fatty acids, which is important in avoiding essential fatty acid deficiencies
• Monogen also provides a complete nutrient profile, including trace elements, to minimize the risk of nutrient deficiencies.

Monogen is prescribed and is medically necessary in this instance as the optimum treatment for [Patient's Name] with a diagnosis of _______________________________________.  I respectfully request insurance (Condition) reimbursement/coverage for the Monogen. The reimbursement code for this product is 49735-0197-08.  The HCPCS Code for this product is B4150 or B4158.

Sincerely,

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