Letter of Medical Necessity

Date:

Patient Name: Jane Doe

 

Patient DOB: mm/dd/yyyy

 

Insurance ID:

 

To whom it may concern:

I am writing in the capacity of a Primary Care Physician / Cardiologist / Neurologist / Gastroenterologist for Jane Doe who has been under my care since January of 2013. Jane has been diagnosed with Postural Orthostatic Tachycardia Syndrome (ICD-10 Code: I49.8).

I am recommending the following treatment:

NormaLyte® ORS (any flavor) - 2 packets (each dissolved in 500mL drinking water) to be taken by mouth daily for a period of 1 year (subject to extension).

The primary goal of the treatment is to achieve and maintain adequate blood volume and blood pressure. To achieve the stated goal, patient is required to consume an additional 4 Grams of salt, combined with 1 Liter of fluids, besides the normal daily dietary intake.  This can be achieved by using suitable Oral Rehydration Salts (ORS) product which has been formulated by adopting the World Health Organization’s (WHO) recommendations and standards.

I certify that the treatment using oral rehydration salts (ORS), classified as medical food by the US FDA, is medically necessary to treat the specific medical condition described above and is not for cosmetic purposes or for treatment which is merely beneficial to the general health of the individual. I am convinced that NormaLyte ORS will reduce the frequency of symptoms associated with patient’s condition. I also believe that this treatment will assist Jane Doe to achieve and maintain maximum functional capacity in performing daily activities. This treatment may potentially reduce the frequency of Intravenous administration of Normal Saline.

I respectfully request insurance reimbursement/coverage for NormaLyte ORS for my patient Jane Doe.

 

Product Name

Reimbursement Code / NDC Format Code

HCPCS Code

NormaLyte ORS (Orange) 6 x 0.37 oz  (10.5 g)

61846-0000-01

B4102 or B4103

NormaLyte ORS (Grape) 6 x 0.37 oz  (10.5 g)

61846-0000-02

B4102 or B4103

NormaLyte ORS (Green Apple) 6 x 0.37 oz  (10.5 g)

61846-0000-03

B4102 or B4103

NormaLyte ORS (Pure) 6 x 0.38 oz  (10.7 g)

61846-0000-04

B4102 or B4103

 

Please reach out to me in case you need specific details about past successes with this treatment, past treatments, patient compliance with other regimens or any reference materials.

 

Sincerely,

 

Signature

Dr. John Doe, MD

NPI: