Dear Sir:

On behalf of my patient, Patient's name, I am submitting this letter to explain the medical condition for which I prescribe the Phlexy-10 System.

Explain medical diagnosis and treatment.

Phlexy-10 System consists of three medical foods and a vitamin/mineral supplement, Phlexy-Vits, designed specifically for the management of phenylketonuria (PKU) in patients one year and older. The Phlexy-10 System includes three interchangeable amino acid supplements - a drink mix, bars, and capsules. These products are the major source of essential amino acids necessary for life, and constitute the principle medical treatment for individuals with PKU. Each bar, 20 capsules or one packet of drink mix provides an equal amount of amino acids thus allowing the patient to choose the most appropriate product for his or her lifestyle.

The Phlexy-10 System 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 the Phlexy-10 System.

The reimbursement codes for these products are:
 

Phlexy-10 Drink Mix	49735-0114-67
Phlexy-10 Bars	49735-0100-77
Phlexy-10 Capsules	49735-0101-36
Phlexy-Vits	49735-0106-85

Sincerely,

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