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Food Allergy
JaredandKatie
member
How to get insurance to pay. Please help.
JaredandKatie
member
in Food Allergy
It seems like most of you have been helped by your insurance provider to pay for formula. I EBF my DD for 5 months but was unable to continue becuse she had diahhrea every stool and hives whenever I ate anything containing dairy, soy, egg, nut, wheat, or oats. We have tried alimentum RTF for a week and half. She was seemingly fine until yesterday when diahrrea returned and she's starting to get a rash.
Alimentum is expensive but Neocate is insanely expensive. How have you received coverage if your insurance company denied you at first? How do you appeal?
This discussion has been closed.
Re: How to get insurance to pay. Please help.
i also googled something about appealing medical coverage for sample letters so i knew what to write. this is my letter except for the heading and stuff...
To Whom It May Concern:
Please accept this letter as Rowan XXXXX?s appeal to MedImpact?s decision to deny coverage for Neocate infant formula or any other amino acid based formula. It is my understanding that Neocate has been denied coverage because it was considered an over the counter nutritional supplement.
So far in Rowan?s two months of life she has been diagnosed with milk protein enterocolitis, food protein induced proctocolitis, milk/soy protein allergy, and gastroesophageal reflux as evidenced by blood and mucus in stools, anal fissures, abdominal pain during and after feedings, allergy rash, and reflux of milk with wheezing. It is the opinion of Doctors David Ferenci (pediatric gastroenterologist), Julie Vogel (family practioner), and Stephanie Fox (pediatric allergist) that Rowan needs an amino acid based formula to eliminate exposure to food allergens. Enclosed is a letter of medical necessity from Dr. Ferenci stating the reasons for needing Neocate, as well as the possible ramifications of not receiving this medical food.
Rowan was fed only breast milk for the first two weeks of life and then the bloody stools and all her other symptoms listed above began. As her mother, I eliminated dairy and soy (as well as other common allergens) from my diet completely for a period of three weeks with no improvement in Rowan?s symptoms. In fact, her symptoms worsened showing that she presumably has other food protein allergies beyond dairy and soy. At that time it was necessary for her to be switched from breast milk to a formula for infants with food protein sensitivities, so as to avoid potential anemia and worsening reactions to allergens. Rowan began taking Similac Alimentum and initially had a significant improvement in her symptoms. Within two days Rowan?s allergy rash, bloody stools, and over all discomfort were lessened. However in the 5 weeks that Rowan has been on Alimentum it has been found that Rowan still suffers from reflux, anal fissures, and bloody stools. These symptoms are evidence of allergy reaction to the casein in the Alimentum. The last medical food that we can use for Rowan short of parenteral nutrition would be an amino acid based formula. Neocate, designed specifically to feed infants with various medical conditions including food protein allergies, is not stocked on store shelves available to the general public and requires being purchased through a pharmacy. Therefore, Neocate is a exempt infant formula and medical food rather than an ?over the counter nutritional supplement.? Please refer to enclosure regarding the FDA?s definition of exempt infant formulas and medical foods.
Based on this information, I am asking you to reconsider your previous decision and allow coverage for an amino acid based formula, such as the Neocate, which has been prescribed. Should additional information need to be provided, please do not hesitate to contact me at xxxx. I look forward to hearing from you in the near future.
Sincerely,
Kristin xxxxx
Rowan?s mother
Exempt Infant Formula:
Food and Drug Administration, HHS
21 CFR Ch. 1 (4-1-97 Edition)
? 107.50
Subpart C - Exempt Infant Formulas
(c) Infant formulas not generally available at the retail level. (1) These exempt infant formulas are not generally found on retail shelves for general consumer purchase. Such formulas typically are prescribed by a physician and must be requested from a pharmacist, or are distributed directly to institutions such as hospitals, clinics, and state or federal agencies. Such formulas are also generally represented and labeled solely to provide dietary management for specific diseases or conditions that are clinically serious or life threatening and generally are required for prolonged periods of time.
Medical Food:
Food and Drug Administration, HHS
21 CFR Ch. 1 (4-1-95 Edition)
? 101.9
(8) Medical foods as defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)). A medical food is 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. A food is subject to this exemption only if:
It is a specially formulated and processed product (as opposed to a naturally occurring foodstuff used in its natural state) for the partial or exclusive feeding of a patient by means of oral intake or feeding by tube;
It is intended for the dietary management of a patient who, because of therapeutic or chronic medical needs, has limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foodstuffs or certain nutrients, or who has other special medically determined nutrient requirements, the dietary management of which cannot be achieved by the modification of the normal diet alone;
It provides nutritional support specifically modified for the management of the unique nutrient needs that result from the specific disease or condition, as determined by medical evaluation;
It is intended to be used under medical supervision; and
It is intended only for a patient receiving active and ongoing medical supervision wherein the patient requires medical care on a recurring basis for, among other things, instructions on the use of the medical food.
From the Office of the Federal Register, National Archives and Records Administration