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A Gray Area for Reimbursement: Medical Foods for Non–Inborn Errors of Metabolism
Leslie Wilson, PhD; Tracy Kuo Lin, MSc, PhD; Anna Oh, RN, MPH; and Vicky Cao, PharmD
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Zhou Zhou, MS; Zheng-Yi Zhou, PhD; Sneha S. Kellar, MPH; Vanja Sikirica, PharmD, MPH; Jipan Xie, MD, PhD; and Regina Grebla, PhD
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A Gray Area for Reimbursement: Medical Foods for Non–Inborn Errors of Metabolism

Leslie Wilson, PhD; Tracy Kuo Lin, MSc, PhD; Anna Oh, RN, MPH; and Vicky Cao, PharmD
Most non–inborn errors of metabolism (non-IEM) medical foods (MFs) do not meet the regulatory MF definition and lack scientific evidence for safety and efficacy. Non-IEM MFs are not yet ready for reimbursement by public insurers.

Objectives: The use of medical foods (MFs) specifically for non–inborn errors of metabolism (non-IEM) is rising. Concomitantly, evidence for the safety and efficacy of these non-IEM MFs is lacking. We examined the current use and costs of non-IEM MFs and determined whether the scientific evidence supporting their effectiveness and medical utility is adequate to warrant public reimbursement.

Study Design: We employed a qualitative literature review analysis.

Methods: PubMed and MEDLINE databases were searched for all years using relevant keywords, including names of non-IEM MFs identified in the California Workers’ Compensation System (CAWCS) claims dataset from 2011 to 2013. The quality of extracted data was scored with the Delfini Evidence Tool Kit.

Results: Only 2 (3.2%) of 62 studies were conducted with scientific rigor. These 2 studies were for dietary management of Alzheimer disease, which does not have a distinctive nutritional requirement necessitating an MF. Seventy-one percent of the studies of MFs used by patients in the CAWCS were considered to have uncertain validity.

Conclusions: Most reviewed non-IEM MFs lack evidence to support their safety and efficacy. These non-IEM MFs do not abide by FDA draft guidance, as they do not address a distinct nutritional requirement for a disease and yet often have a National Drug Code or “Rx only” label. Consequently, these products do not meet the statutory definition of an MF. We recommend that CAWCS and other payers not provide insurance coverage for non-IEM MFs until more scientific evidence supports their safety, efficacy, and use for nutritional need of a disease.

Am J Manag Care. 2018;24(Spec Issue No. 8):SP273-SP278

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