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The template includes insured and policy details, required patient information, and a prescribed daily amount of calories or bottles. It states that the peptide-based, nutritionally complete formula supports tolerance and absorption and lists relevant indications and ICD-10 diagnosis examples. It also provides provider signature fields and enclosure notes, with guidance that coding lists are not exhaustive.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/pediasure-peptide-sample-letter-of-medical-necessity-coverage-and-reimbursement-request/170997/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/pediasure-peptide-sample-letter-of-medical-necessity-coverage-and-reimbursement-request/170997.png","ImageObject",442,249,{"name":88,"@type":89},"Sarah ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-20","2026-09-01",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",19,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"What information does the physician need to complete in the template?","Question",{"text":109,"@type":110},"The template requests the patient’s name, DOB, current weight and length/height, time under care, diagnosis, and other applicable notes, plus the insured and policy details and the prescribed daily calories/bottles.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What medical rationale does the letter provide for using PediaSure Peptide?",{"text":114,"@type":110},"It states the formula is nutritionally complete and peptide-based and is necessary for medical management to support tolerance and absorption for children with malabsorption, maldigestion, and other GI conditions.",{"name":116,"@type":107,"acceptedAnswer":117},"Which types of conditions and ICD-10 codes are referenced?",{"text":118,"@type":110},"The letter lists examples such as Crohn’s disease, ulcerative colitis, functional digestive disorders, postsurgical malabsorption, noninfectious gastroenteritis/colitis, chronic or acute pancreatitis, cerebral palsy, and failure to thrive, with associated ICD-10 examples.",{"name":120,"@type":107,"acceptedAnswer":121},"Are the diagnosis and ICD-10 code lists guaranteed to be complete?",{"text":122,"@type":110},"No. The template notes the diagnosis/code list is not all-inclusive, and healthcare professionals are responsible for determining and documenting the appropriate diagnosis(es) and code(s).","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},170997,1788278550,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":130,"read_time":9},962085320529,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","PediaSure Peptide® Sample Letter of Medical Necessity\n(Insert Provider Letterhead and Address)\n(Date)\n(Health Insurance Plan Contact)\n(Title)\n(Name of Health Insurance Plan)\n(Address)\n(City, State, Zip)\nInsured: (Name)\nPolicy Number: (Number)\nGroup Number: (Number)\nDear (Name of Contact)\nI am requesting insurance coverage and reimbursement of PediaSure Peptide for ___________________.\n(Patient’s Name)\nThe use of PediaSure Peptide, a nutritionally complete, peptide-based formula, is necessary for the medical management of this patient.\nPatient Information (to be completed by the physician)\n•\tPATIENT’S NAME\n•\tDOB\n•\tCURRENT WEIGHT\n•\tCURRENT LENGTH/HEIGHT\n•\t# OF MONTHS/YEARS UNDER MY CARE\n•\tDIAGNOSIS\n•\tOTHER (if applicable)\nBased on my patient’s current medical condition, I am prescribing ___________calories/bottles per day of PediaSure Peptide.\nPediaSure Peptide is a nutritionally complete, peptide-based formula for the nutritional needs of children with malabsorption, maldigestion and other GI conditions in which a peptide-based formula is appropriate. PediaSure Peptide contains a nutrient blend designed to help support tolerance and absorption, including:\nPrebiotics from Nutraflora® scFOS®*,\n60% MCT and structured lipids,\nHydrolyzed, whey-dominant protein\nPediaSure Peptide is designed to meet the dietary needs of children with the following conditions:\nCrohn’s Disease, unspecified (K50.90)\nUlcerative Colitis, unspecified w/o complications (K51.90)\nFunctional digestive disorder, unspecified (K59.9)\nPostsurgical malabsorption, not elsewhere classified (K91.2)\nNoninfectious gastroenteritis and colitis, unspecified (K52.9)\nOther chronic pancreatitis (K86.1)\nCerebral Palsy, unspecified (G80.9)\nAcute pancreatitis, unspecified (K85.9)\nFailure to thrive (child) (R62.51)\nFat Malabsorption, Protein Maldigestion (K90-)\nLactose Sensitivity (E73.9)\nOther conditions in which a peptide-based diet would be beneficial (e.g., tube feeding- associated GI intolerance, critical illness-associated GI dysfunction, early enteral feeding, transition from TPN)\n(– Means code can be used in the entire family ending with the last digit)\nPediaSure Peptide is a medical food intended for use under supervision of a medical professional. Your approval of this request for coverage and reimbursement will make a significant difference in the health of this patient.\nSincerely,\n________________________________________  (Physician’s Signature)\n_________________________________________  (Physician’s Printed Name)\n*Nutraflora® and scFOS9® are not registered trademarks of Abbott Laboratories\nEnclosure(s): Prescription, Doctor’s Notes and Reports, Growth Chart, etc\nThis letter is intended to be used as a template and customized by the physician for each patient. The list of diagnoses and ICD-10 codes contained in this letter is not all-inclusive. It is ultimately the responsibility of the health care professional/persons associated with the patient's care to determine and document the appropriate diagnosis(es) and code(s) for the patient's condition. Abbott Nutrition does not guarantee that the use of any information provided in this letter will result in coverage or payment by any third-party payer.\nSource of ICD-10 codes: \u0013 HYPERLINK \"https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx\" \u0014https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx\u0015\nProduct and Coding Information for PediaSure Peptide\n*Abbott Nutrition does not represent these codes to be actual National Drug Codes (NDCs). NDC-format codes are product codes adjusted according to standard industry practice to meet the format requirements of pharmacy and health insurance systems","cbCaihgEr56KcmgY","https://ap.wps.com/l/cbCaihgEr56KcmgY","docx",28730,"English","# Request Letter Sections\n## Insured and Policy Information\n## Patient Information and Physician Prescription\n## Indications and ICD-10 Diagnosis Examples\n## Signature, Disclaimers, and Enclosures","[{\"question\":\"What information does the physician need to complete in the template?\",\"answer\":\"The template requests the patient’s name, DOB, current weight and length/height, time under care, diagnosis, and other applicable notes, plus the insured and policy details and the prescribed daily calories/bottles.\"},{\"question\":\"What medical rationale does the letter provide for using PediaSure Peptide?\",\"answer\":\"It states the formula is nutritionally complete and peptide-based and is necessary for medical management to support tolerance and absorption for children with malabsorption, maldigestion, and other GI conditions.\"},{\"question\":\"Which types of conditions and ICD-10 codes are referenced?\",\"answer\":\"The letter lists examples such as Crohn’s disease, ulcerative colitis, functional digestive disorders, postsurgical malabsorption, noninfectious gastroenteritis/colitis, chronic or acute pancreatitis, cerebral palsy, and failure to thrive, with associated ICD-10 examples.\"},{\"question\":\"Are the diagnosis and ICD-10 code lists guaranteed to be complete?\",\"answer\":\"No. The template notes the diagnosis/code list is not all-inclusive, and healthcare professionals are responsible for determining and documenting the appropriate diagnosis(es) and code(s).\"}]","PediaSure Peptide Sample Letter of Medical Necessity - Coverage and Reimbursement Request | DOCX"]