TO:
Case Review Services
Re: Ketogenic Diet Therapy
For: ________________________
DOB: ________________________
Attention Case Manager:
___________________________________ is a _____-month-old boy/girl with a diagnosis of ____________________________ and an intractable seizure disorder. (His/Her) seizures were occuring _____ times each day despite attempts at seizure control with ____________________________________ (name anticonvulsants here).
The ketogenic diet is a high fat, adequate protein, low carbohydrate formula that is individually calculated and prescribed to produce adequate ketosis to suppress the child’s seizures. The formula, which is fed by (bottle/gastrostomy tube), comprises __________________. The formula must be supplemented with multivitamins and minerals in order to be nutritionally complete.
We are requesting that, because these components constitute an antiepileptic therapy rather than just a nutritional formula, they be covered under your policies.
Thank you for helping_______________________________to develop as free of seizures and medications as possible.
Sincerely,
XXX