Date: November 10, 2010
TO: Insurance Company
FROM: John Smith, MD
SUBJECT: Request for coverage/ reimbursement for Compleat® Pediatric tube feeding
I am requesting insurance coverage and reimbursement on behalf of my patient, Name/Date of
Birth. I have prescribed Compleat® Pediatric formula, manufactured by Nestlé HealthCare
Nutrition, Inc. for the dietary management of Diagnosis or Condition.
Verify medical necessity for this product. Diagnosis; Documented failure on another formula;
Height/Weight/Ideal Body Weight; Pertinent lab values; Pertinent meds; Potential outcome if
therapy were denied and patient did not receive formula prescribed.
Compleat® Pediatric formula is designed for children ages 1 - 10 with intolerance to standard
tube feeding formulas. This product is intended for the nutritional management of those
pediatric patients with special health needs, constipation, diarrhea, developmental disabilities
and/ or those requiring a long term tube feeding regimen and desire a real food component.
Compleat® Pediatric is a medical food for use under the supervision of a medical professional.
There is a concern that an individual who is denied coverage for a commercially blenderized
formula may try to prepare a “homemade” formula, thus increasing the potential for bacterial
contamination and nutrient variability.
Although standard and commercially blenderized enteral formulas provide high quality nutrition,
blenderized enteral feedings contain real food ingredients. Compleat® Pediatric formula is
recognized by the Centers for Medicare and Medicaid Services (CMS) as an enteral formula,
manufactured blenderized natural foods with intact nutrients, includes proteins, fats,
carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding
tube, found in HCPCS Category B4149.
1. Ling et al. Home parenteral nutrition in a child with Menetrier disease. European Journal of Pediatrics.
Volume 144, Number 5, 505-507, DOI: 10.1007/BF00441749
2. Abu-Elmagd et al. THREE YEARS CLINICAL EXPERIENCE WITH INTESTINAL
TRANSPLANTATION. J Am Coll Surg. 1994 October; 179(4):385-400.
Thank you for taking the time to review this request. Please contact me should you require any
Attachments: Include pertinent information supporting evidence of medical necessity
Product Packaging Product Code NDC Format Number HCPCS Code
Compleat® 24-250 mL 14240000 00212-1424-51 B4149
Pediatric cans/ case
*First Data Bank NDC Format Number – Since Nestlé no longer prints NDC Format Codes on product labels, FDB
uses the product UPC code to create a number that can be found in the “NDC” field of the FDB publication for
products introduced after 2007.
Nestlé HealthCare Nutrition
Unit of Measure: Serving
COMPLEAT® PEDIATRIC Product: COMPLEAT® PEDIATRIC
Nutritionally complete, pediatric tube Type of Diet: Blenderized Tube Feeding / Pediatric
feeding containing blenderized foods. Source: Nestlé Nutrition
For children 1 to 10 years.
Prefilled System: No
Serving Size: 250 mL
Calories per mL: 1
Protein (gm): 9.5
Protein (% kcal): 15%
Protein Source: Chicken, Sodium Caseinate, Pea Puree
Carbohydrate (gm): 32.5
Carbohydrate (% kcal): 50%
Carbohydrate Source: Corn Syrup Solids, Cranberry Juice, Fruits, Vegetables
Fat (gm): 9.8
Fat (% kcal): 35%
Fat Source: Canola Oil, MCT Oil, Chicken Fat
Osmolality (mOsm/Kg): 380
mL to Meet 100% RDI*: 900 mL (Ages 1-10)
Fiber Content (gm): 1.7
Fiber Source: Partially Hydrolyzed Guar Gum, Vegetables, Fruits
Free H2O: 82%
Product: COMPLEAT® PEDIATRIC Product: COMPLEAT® PEDIATRIC
Vitamin A (IU): 825.0 Sodium (mg): 192.5
Beta-Carotene (mg): N/A Sodium (mEq): 8.25
Vitamin D (IU): 82.5 Potassium (mg): 400.0
Vitamin E (IU): 5.25 Potassium (mEq): 10.25
Vitamin K (mcg): 9.5 Chloride (mg): 140.0
Vitamin C (mg): 24.0 Chloride (mEq): 4.0
Thiamine-B1 (mg): 0.65 Calcium (mg): 360.0
Riboflavin-B2 (mg): 0.5 Calcium (mEq): 18.0
Niacin (mg): 4.0 Phosphorus (mg): 250.0
Vitamin B6 (mg): 0.6 Magnesium (mg): 57.5
Folic Acid (mcg): 87.5 Iron (mg): 3.25
Pantothenic Acid (mg): 2.4 Iodine (mcg): 32.5
Vitamin B12 (mcg): 1.4 Copper (mg): 0.3
Biotin (mcg): 75.0 Zinc (mg): 3.0
Choline (mg): 125.0 Manganese (mg): 0.55
Taurine (mg): 21.0 Selenium (mcg): 13.0
L-Carnitine (mg): 4.0 Molybdenum (mcg): 14.0
M-Inositol (mg): 19.0 Chromium (mcg): 22.0
All product information is obtained from product literature as available upon the date of issue . Every effort was made to ensure that
all product information is accurate. It is, however, subject to change. For the most up-to-date specific nutritional information, please
consult Nestlé HealthCare Nutrition. For assistance in product selection and clinical application, call Nestle Info Link at
* for key nutrients. Pediatric products reference NAS-NRC_RDA (1989).