Form Mnr-Enp - Masshealth Prescription And Medical Necessity Review Form For Enteral Nutrition Products Page 2

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Member Name:

SECTION 6

Section 6 must be completed by the member’s prescribing provider or his or her staff. Complete all items and attach any pertinent information

(i.e. lab tests, medical history and physical examination, clinical notes, etc.).

A. Anthropometric Measures (Complete all items).

Height:

Basal Metabolic Rate (BMR):

Body Mass Index (BMI):

Weight:

Growth Percentile (Child Only):

Ideal Body Weight:

B. Laboratory Tests (Attach Results).

Type of blood tests (specify):

Type of urine tests (specify):

Other tests (specify):

C. Risk Factors

Anatomic structures of gastrointestinal tract that impair digestion and absorption

Neurological disorders that impair swallowing or chewing (specify):

Diagnosis of inborn errors of metabolism that require food products modified to be low in protein (specify):

Intolerance or allergy to standard milk-based or soy infant formulas that have improved with a trial of specialized formula

Prolonged nutrient losses due to malabsorption syndromes or short-bowel syndromes, diabetes, celiac disease, chronic pancreatitis, renal dialysis,

draining abscess or wounds, etc. (specify type):

Treatment with anti-nutrient or catabolic properties

Increased metabolic and/or caloric needs due to excessive burns, infection, trauma, prolonged fever, hyperthyroidism, or illnesses that impair caloric

intake and/or retention

A failure-to-thrive diagnosis that increases caloric needs while impairing caloric intake and/or retention

Other (specify):

D. Route of Treatment

Mouth (oral) only

Nasogastric (NG-tube)

Gastric (G-tube)

Jejunal (J-tube)

Other (specify):

E. Treatment Regimen Initiated

Past (explain):

Last Six Months (explain):