Medical Foods & Insurance Coverage

In the treatment of eosinophilic gastrointestinal disorders (EGIDs), amino-acid based elemental formulas are used for diagnostic and therapeutic purposes.

These specialized formulas are considered to be “medical foods,” and when used in the treatment of EGIDs, are just as critical to the treatment plan of some patients as insulin is to a diabetic.

What is a Medical Food?

Medical foods are specially formulated and processed (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 enteral feeding by tube.

Medical foods are 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.

Medical foods provide 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. For additional details about how this is defined, visit the FDA website.

Medical foods should ONLY be used under medical supervision for patients receiving active and ongoing medical care wherein the patient requires medical care on a recurring basis for, among other things, instructions on the use of the medical food.

Are Medical Foods Covered by Insurance?

In some states, these formulas are covered by insurance. In others, they are not. We feel that these medical treatment modalities should be covered by insurance companies, just like any other prescribed pharmaceutical.

To see if your state has legislation mandating insurance coverage of medical foods, see our State Insurance Mandates for Elemental Formula.

I Have Been Denied Coverage for Formula. Can I Appeal?

Insurance companies have denied coverage of medial foods for two reasons: medical necessity was not established, or medical foods not included in the plan coverage.

If you have been denied coverage, see our Guide to Formula Coverage for tips and suggestions.

If you are still not successful, ask your insurance provider what process must be used to submit an appeal. The following documents may help as you go through this process:

1) Template of a letter a patient can use to appeal.
This template references the following attachments:

2) Template of a letter a physician can use to appeal on behalf of a patient.
This template references the following attachments:

How is APFED Supporting Efforts to Have Medical Foods Covered by Insurance?

APFED supports efforts to increase coverage for medical foods at both the national and state level. We partner with other organizations that advocate for insurance coverage of medical foods, such as the Children’s Medical Nutrition Alliance and Children’s Magic. Additionally, we guide volunteers through the legislative process, assist with the formation of coalitions with partner organizations, connect volunteers with one another for mentoring and support, and provide supporting materials and data to volunteers, issuing calls to action as needed.

Resources

State Insurance Mandates for Elemental Formula
Insurance coverage of medical foods
Guide to Formula Coverage
Feeding Tubes
APFED’s Advocacy Work
Children’s MAGIC
FDA Guidance for Industry: Frequently Asked Questions About Medical Food
“Hope. Heal. Cure.” video