Baby’s Only Organic® Formulas
Certificate of Medical Necessity
Baby’s Only Organic® Formulas available in Dairy, Dairy with Whey Protein,
Dairy with DHA & ARA, LactoRelief with DHA & ARA and Soy
Date
To (Insurance Company)
From (Physician’s Name)
(Hospital or Company)
is a
(age) patient who has been under my care for
She/he has a diagnosis of
The patient’s current weight is
years.
, which has been managed with
and height is
He or She will require
calories- kcal/ounces per day.
This may adjust as his or her nutritional needs change. The use of Baby’s Only Organic ® is a key component to the medical management of the patient’s condition.
I am requesting insurance coverage and reimbursement for this patient, for whom I am prescribing Baby’s Only Organic ®.
Organic Dairy Formula with DHA & ARA Offering the ONLY formula with DHA & ARA derived from egg phospholipids.
Studies conclude egg phospholipids are more easily absorbed and offer greater bio-availability than DHA currently used in leading formulas.
Organic Dairy with Whey Protein Formula Contains 100% organic lactose as carbohydrate source; added organic whey protein powder.
May aid in digestion and produce softer stools.
Organic Dairy Formula Healthcare professionals often recommend dairy formula as it naturally contains protein and carbohydrates most
similar to breast milk.
Organic LactoRelief® with DHA & ARA Formula This milk-based formula is intended for babies who are lactose intolerant and offers an
alternative to parents who wish to avoid soy protein in their baby’s diet.
Organic Soy Formula This soy-based formula is lactose and dairy free and appropriate when parents prefer a vegetarian diet.
Protein
HCPCS Code
NDC – Format Code
Source – First Databank
Cal per Can
Baby’s Only Organic®
Dairy
B4158
16514-0229-00
1,680
Baby’s Only Organic®
Dairy with Whey Protein
B4158
16514-2292-70
1,680
Baby’s Only Organic®
Dairy with DHA & ARA
B4158
16514-0229-02
1,680
Baby’s Only Organic®
LactoRelief ® with DHA & ARA
B4158
16514-0229-03
1,680
Baby’s Only Organic®
Soy
B4159
16514-0539-50
1,680
Product
Your approval of this request will make a significant difference in the health and well-being of my patient.
Sincerely,
Physician’s Signature
Date:
R02-P0916