Statement of Medical Necessity for Outpatient Donor Milk

STATEMENT OF MEDICAL NECESSITY FOR OUTPATIENT DONOR MILK

This form is provided as a tool to generate a statement of medical necessity to be used when seeking pre-authorization for donor milk coverage. Submit the completed form to the insurance plan, not the milk bank.
Patient Name*

First NameLast Name
Patient birth date*

MonthDayYear
Date
Insurance Plan*
Policy holder*

First NameLast Name
ID Number*
Group/Group number*
Birth weight*
Current weight*
I am requesting that insurance coverage be provided for pasteurized human donor milk for the above patient. This child is unable to thrive using commercially available formulas or has a documented medical condition that is known to benefit from donor milk.
Infant Diagnosis

Select one or more
Common Infant ICD-10 codes*

R62.51 Failure to thrive in child (0-17 yrs)P07.30 Preterm newborn, unspecified gestationP07.20 Extreme immaturity of newborn, unspecified gestationP05.10 Newborn SGA, unspecified weightK90.9 Intestinal malabsorption, unspecifiedP77.9 Necrotizing enterocolitis in newbornZ91.011 Allergy to milk productsQ79.3 GastroschisisK52.22 Food protein induced enteropathyP27.1 Bronchopulmonary dysplasia originating in the perinatal periodQ24.9 Congenital malformation of heart, unspecifiedJ94.0 Chylous effusionP96.1 Neonatal withdrawal symptoms from maternal use of drugs of addictionG12.0 Spinal muscular atrophy
Additional Codes
Additional Codes
Additional Codes
Additional Codes
Maternal Diagnoses

Select one or more
Common Maternal ICD-10 codes*

O92.3. AgalactiaO92.4 HypogalactiaO92.5 Suppressed lactationO92.79 Other disorders of lactation
Additional Codes
Additional Codes
Formula Trials
Formula*
Dates*
Symptoms*
Formula
Dates
Symptoms
Formula
Dates
Symptoms
Formula has not been trialed due to the following reasons:
Clinical Information

Providers - please fill out the following, as applicable. Attach additional sheets, if necessary.
Donor milk is the only appropriate form of nutrition for this child due to the following:
Improvements observed with donor milk and the ways it is helping this child:
Negative outcomes that could occur without the provision of donor milk for this child:
Describe the child’s treatment plan regarding donor milk:
Additional clinical documentation attached:

Growth chartsTestsNotesOther
File Upload

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Pasteurized Human Donor Milk Requirements
Type of pasteurized human donor milk required:*

TermDefatted
Anticipated amount required: number* oz ml* per day for number* weeks months*
Provider Information

I certify that pasteurized human donor milk is medically necessary for this child and that the information provided is accurate to the best of my knowledge.
Provider Name*
NPI#*
Email*
example@example.com
Phone Number*
Please enter a valid phone number
Fax Number*
Please enter a valid fax number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

Clear
Date*

MonthDayYear
Date
After completing the above required fields, please click on the Preview PDF button below before submitting to obtain your copy.
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STATEMENT OF MEDICAL NECESSITY FOR OUTPATIENT DONOR MILK

Infant Diagnosis

Maternal Diagnoses

Formula Trials

Clinical Information

Pasteurized Human Donor Milk Requirements

Provider Information