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[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>What are the recommendations in data_sources/erisa.pdf [/INST] | persons for appointment as trustees in VerDate Nov 24 2008 19:35 Feb 28, 2023 Jkt 000000 PO 00000 Frm 00402 Fmt 9001 Sfmt 9001 G:\COMP\ERISA\ERISAO1 | persons for appointment as trustees in VerDate Nov 24 2008 19:35 Feb 28, 2023 Jkt 000000 PO 00000 Frm 00402 Fmt 9001 Sfmt 9001 G:\COMP\ERISA\ERISAO1 |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>What are the recommendations in data_sources/hiv_prep_soc.pdf [/INST] | (grade "A") that all adolescents (age ≥15 years) be screened for HIV-
that clinicians inform all sexually -active patients about PrEP and its role in preventing HIV acquisition-
that PrEP be provided to "persons who are at high risk of HIV acquisition" with an A grade indicating that there is high certainty that the net benefit is substantial-
PrEP with F/TDF-
that all adult patients be screened for injection practices or other illicit drug use-
that clinicians be alert to the signs and symptoms of illicit drug use in patients-
the use of F/TDF (or 3TC/efavirenz) for all pregnant and breastfeeding women with HIV to prevent perinatal and postpartum mother -to-child HIV transmission-
that MSM, PWID, patients with a sex partner who has HIV, and others at substantial risk of HIV acquisition undergo an HIV test at least annually or for those with additional risk factors, every 3 -6 months | (grade "A") that all adolescents (age ≥15 years) be screened for HIV-
that clinicians inform all sexually -active patients about PrEP and its role in preventing HIV acquisition-
that PrEP be provided to "persons who are at high risk of HIV acquisition" with an A grade indicating that there is high certainty that the net benefit is substantial-
PrEP with F/TDF-
that all adult patients be screened for injection practices or other illicit drug use-
that clinicians be alert to the signs and symptoms of illicit drug use in patients-
the use of F/TDF (or 3TC/efavirenz) for all pregnant and breastfeeding women with HIV to prevent perinatal and postpartum mother -to-child HIV transmission-
that MSM, PWID, patients with a sex partner who has HIV, and others at substantial risk of HIV acquisition undergo an HIV test at least annually or for those with additional risk factors, every 3 -6 months |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>What are the recommendations in data_sources/wpath_soc7.pdf [/INST] | surgery share the ethical and legal responsibility for that decision with the surgeon-
hormone therapy share the ethical and legal responsibility for that decision with the physician who provides the service-
that hormone providers regularly review the literature for new information and use those medications that safely meet individual patient needs with available local resources-
potential revisions to the SOC as warranted by new evidence-
a minimum number of psychotherapy sessions prior to hormone therapy or surgery | surgery share the ethical and legal responsibility for that decision with the surgeon-
hormone therapy share the ethical and legal responsibility for that decision with the physician who provides the service-
that hormone providers regularly review the literature for new information and use those medications that safely meet individual patient needs with available local resources-
potential revisions to the SOC as warranted by new evidence-
a minimum number of psychotherapy sessions prior to hormone therapy or surgery |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>What are the recommendations in data_sources/Standards of Care for the Health of Transgender and Gender Diverse People Version 8.pdf [/INST] | against using CEE when estradiol is an available treatment option-
institutional administrators, health care professionals, and other officials responsible for making housing decisions for tgd residents consider the individual’s housing preference, gender identity and expression, and safety considerations rather than solely their anatomy or sex assignment at birth-
health care providers understand the impact of social attitudes, laws, economic circumstances, and health systems on the lived experiences of transgender and gender diverse people worldwide-
health care professionals who are assessing eunuch individuals for treatment have demonstrated competency in assessing them-
institutional personnel allow tgd residents the private use of shower and toilet facilities upon request-
surgeons who perform gender-affirming surgical procedures have the following credentials:13-
following best practice guidelines for language translation to ensure high quality written resources are produced that are culturally and linguistically appropriate to the local situation-
HCPs discuss with their patients what language or terminology they prefer be used when referring to them-
health care professionals measure hormone levels during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at levels appropriate for the treatment goals of transgender and gender diverse people according to the tanner stage-
gender-affirming medical and surgical treatment (GAMST), only one letter of assessment from a member of the multidisciplinary team is needed-
patients who regret their gender-related surgical intervention be managed by an expert multidisciplinary team-
all institutional staff address tgd individuals by their chosen names and pronouns at all times-
health care professionals work with families, schools, and other relevant settings to promote acceptance of gender diverse expressions of behavior and identities of the adolescent-
HCPs offering consultation, psychotherapy, or both to gender diverse children and families/caregivers provide both par ties with age appropriate psycho-education about gender development-
health care professionals counsel transgender and gender diverse people that the use of antiretroviral medications is not a contraindication to gender-affirming hormone therapy-
health care professionals begin pubertal hormone suppression in eligible* transgender and gender diverse adolescents only after they first exhibit physical changes of puberty (Tanner stage 2)-
against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender and gender diverse people undergoing testosterone treatment and who have an otherwise average risk of malignancy-
health care professionals providing care for transgender youth and adults seek training and education in the aspects of intersex care relevant to their professional discipline-
health care professionals follow local breast cancer screening guidelines developed for cisgender women in their care of transgender and gender diverse people with breasts from natal puberty who have not had gender-affirming chest surgery-
health care professionals use GnRH agonists to suppress endogenous sex hor mones in eligible* transgender and gender diverse people for whom puberty blocking is indicated-
be enacted across the various relationships and settings in which a young person exists and functions-
health care professionals who are treating transgender and gender diverse people and prescribing or referring patients for hormone therapies/surgeries advise their patients about:a-
health care professionals who provide care to transgender and gender diverse people discuss the impact of gender-affirming treatments on sexual function, pleasure, and satisfaction-
their routine use in trans feminine populations-
all members of the health care workforce receive cultural-awareness training focused on treating transgender and gender diverse individuals with dignity during orientation and as part of annual or continuing education-
health care professionals and other users of the Standards of Care, Version 8 guidelines should apply the recommendations in ways that meet the needs of eunuch individuals-
surgeons consult a comprehensive, multidisciplinary team of professionals in the field of transgender health when eligible* transgender and gender diverse people request individually customized (previously termed "non-standard") surgeries as part of a gender-affirming surgical intervention-
health care professionals who provide care to transgender and gender diverse people offer the possibility of including the partner(s) in sexuality-related care, if appropriate-
health care professionals apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of transgender and gender diverse people who have the same risks-
health care professionals offering consultation, psychotherapy, or both to gender diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being-
health care professionals provide nonbinary people with individualized assessment and treatment that affirms their experience of gender-
gender-affirming medical and sur gical treatment (GAMST) for an adolescent, only one letter of assessment from a member of the multidisciplinary team is needed-
families be offered ongoing peer and professional psychosocial support (Hughes et al-
medical professionals charged with prescribing and monitoring hormones for tgd individuals living in institutions who need gender-affirming hormone therapy do so without undue delay and in accordance with the soC-8-
health care professionals consider gender-affirming surgical interventions in the absence of hormonal treatment, unless hormone therapy is required to achieve the desired surgical result-
health care professionals working with gender diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender diverse children-
health care professionals counsel individuals with intersexuality and their families about puberty suppression and/or hormonal treatment options within the context of the individual's gender identity, age, and unique medical circumstances-
health care professionals provide information to nonbinary people about the effects of hormonal therapies/surgery on future fertility and discuss the options for fertility preservation prior to starting hormonal treatment or undergoing surgery-
all personnel working in governmental, nongovernmental, and private agencies receive cultural-awareness training focused on treating transgender and gender diverse individuals with dignity and respect-
institutions involved in the training of health professionals develop competencies and learning objectives for transgender and gender diverse health within each of the competency areas for their specialty-
institutional personnel establish housing policies that ensure the safety of transgender and gender diverse residents without segregating or isolating these individuals-
that health care professionals conducting an assessment with gender diverse children consider relevant developmental factors, neurocognitive functioning and language skills-
health care professionals in transgender health inform transgender and gender diverse people commencing testosterone therapy of the potential and variable effects of this treatment on voice and communication-
all members of the health care workforce receive cultural-knowledge training focused on treating transgender and gender diverse individuals with dignity during orientation and as part of annual or continuing education-
the health care professionals working with gender diverse children receive training and have expertise in gender development and gender diversity in children and possess general knowledge of gender diversity across the life span-
voice and communication specialists assess current and desired vocal and communication function of transgender and gender diverse people and develop appropriate intervention plans for those dissatisfied with their voice and communication-
conjugated equine estrogens (CEEs) as a treatment option because blood levels of conjugated estrogens cannot be measured in transgender women making it difficult to prevent supraphysiologic dosing of estrogen and thereby increasing the potential risk of VTE (Hembree et al-
staff and professionals charged with providing health care to tgd individuals living in institutions recommend and support gender-affirming surgical treatments in accordance with the soC-8 when sought by the individual, without undue delay-
health care professionals conducting an assessment with gender diverse children consider relevant developmental factors, neurocognitive functioning, and language skills-
health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people-
health care professionals who provide care to transgender and gender diverse people acquire the knowledge and skills needed to address sexual health issues (relevant to their care provision)-
that health care professionals provide information to gender diverse children and their families/caregivers as the child approaches puberty about potential gender affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation-
mental health professionals offer care and support to transgender and gender diverse people to address mental health symptoms that interfere with a person’s capacity to participate in essential perioperative care before gender-affirmation surgery-
health care professionals offer cervical cancer screening to transgender and gender diverse people who currently have or previously had a cervix following local guidelines for cisgender women-
stopping the use of tobacco/nicotine prior to gender-affirmation surgery and abstaining from smoking up to several weeks postoperatively until the wound has completely healed (Matei & Danino, 2015)-
surgeons caring for transgender women and gender diverse people who have undergone vaginoplasty encourage follow-up with their primary surgeon, primary care physician, or gynecologist-
health care providers involve professionals from multiple disciplines who are experts in transgender health and in the management of the care of transgender and gender diverse adolescents-
health care professionals educate transgender and gender diverse people undergoing gender-affirming treatment about the onset and time course of physical changes induced by sex hormone treatment-
health care professionals counsel transgender and gender diverse people about the potential impact of stigma and trauma on sexual risk behavior, sexual avoidance, and sexual functioning-
administrators, health care professionals, and all others working in institutions charged with the responsibility of caring for tgd individuals allow those individuals who request appropriate clothing and grooming items to obtain such items concordant with their gender expression-
health care professionals in transgender health working with transgender and gender diverse people who are dissatisfied with their voice or communication consider offering a referral to voice and communication specialists for voice-related support, assessment, and training-
health care professionals assessing adults who wish to detransition and seek gender-related hormone intervention, surgical intervention, or both, utilize a comprehensive multidisciplinary assessment that will include additional viewpoints from experienced health care professional in transgender health and that considers, together with the individual, the role of social transition as part of the assessment process-
health care professionals assessing transgender and gender diverse adults for gender-affirming medical and surgical treatment:5-
health care professionals working with gender diverse children receive training and have expertise in gender development and gender diversity in children and possess a general knowledge of gender diversity across the life span-
the application of the Standards of Care (SOC) to people living in institutions as basic principles of health care and ethics (Beauchamp & Childress, 2019; Pope & Vasquez, 2016)-
its routine use-
health care professionals obtain a detailed medical history from transgender and gender diverse people, that includes past and present use of hormones, gonadal surgeries, as well as the presence of traditional cardiovascular and cerebrovascular risk factors with the aim of providing regular cardiovascular risk assessment according to established, locally used guidelines-
health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:6-
institutional administrators, health care professionals, and other officials responsible for making housing decisions for TGD residents consider the individual’s housing preference, gender identity and expression, and safety considerations, rather than solely their anatomy or sex assignment at birth-
testing be carried out every 3 months in the first year to allow some flexibility on the timing of these tests as there is no strong evidence or evidence from published studies supporting specific testing intervals-
health care professionals and other users of the s tandards of Care, Version 8 (soC-8) apply the recommendations in ways that meet the needs of local transgender and gender diverse communities, by providing culturally sensitive care that recognizes the realities of the countries they are practicing in-
health care professionals should not make it mandatory for transgender and gender diverse people to undergo psychotherapy prior to the initiation of gender-affirming treatment, while acknowledging psychotherapy may be helpful for some transgender and gender diverse people-
health care professionals discuss bone health with transgender and gender diverse people including the need for active weight bearing exercise, healthy diet, calcium, and vitamin d supplementation-
health care professionals working with gender diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum-
health care professionals consider gender-affirming surgical interventions in the absence of hormonal treatment unless hor mone therapy is required to achieve the desired surgical result-
health care professionals prescribe testosterone-lowering medications (either cyproterone acetate, spironolactone, or GnRH agonists) for eligible* transgender and gendered diverse people with testes taking estrogen as part of a hormonal treatment plan if their individual goal is to approximate levels of circulat ing sex hormone in cisgender women-
health care professionals counsel pre- or early-pubertal transgender and gender diverse youth seeking gender-affirming therapy and their families that currently evidence-based/established fertility preservation options are limited-
voice and communication specialists working with transgender and gender diverse people receive specific education to develop expertise in supporting vocal functioning, communication, and well-being in this population-
all personnel working in governmental, nongovernmental, and private agencies receive cultural-knowledge training focused on treating transgender and gender diverse individuals with dignity and respect-
scheduled risk assessments using a calculated prediction of ten-year total CVD risk based on risk prediction equations from large population samples-
health care providers involve professionals from multiple disciplines who are experts in transgender health and in the management of the care required for transgender and gender diverse adolescents-
health care professionals (HCPs) utilize local language and terms to deliver care in their specific cultural and/or geographical locale-
providers who offer pregnancy termination services ensure procedural approaches are gender-affirming and serve transgender people and those of diverse genders-
health care professionals who are prescribing or referring for hormonal therapies/surgeries counsel individuals with intersexuality and fertility potential and their families about a) known effects of hormonal therapies/surgery on future fertility; b) potential effects of therapies that are not well studied and are of unknown reversibility; c) fertility preservation options; and d) psychosocial implications of infertility-
health care professionals obtain a detailed medical history from transgender and gender diverse people that includes past and present use of hormones, gonadal surgeries as well as the presence of traditional osteoporosis risk factors, to assess the optimal age and necessity for osteoporosis screening-
when significant mental health symptoms or substance abuse exists, mental health professionals assess the potential negative impact mental health symptoms may have on outcomes based on the nature of the specific gender-affirming surgical procedure-
surgery be offered to very young children (American Urological Association, 2019; Pediatric Endocrine Society, 2020)-
providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding-
health care professionals responsible for providing gender-affirming care to individuals residing in institutions (or associated with institutions or agencies) recognize the entire list of recommendations of the SOC-8, apply equally to TGD people living in institutions-
voice and communication specialists assess current and desired vocal and Statements of Recommendations14-
health care professionals working with transgender and gender diverse people who are considering undergoing voice surgery consider offering a referral to a voice and communication specialist who can provide pre- and/or postoperative support-
"reparative" and "conversion" therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered-
surgical outcomes be tracked and communicated to the patients as part of the informed consent (Schechter et al-
transgender and gender diverse people with a uterus who wish to carry a pregnancy undergo preconception care and prenatal counseling regarding the use and cessation of gender-affirming hormones, pregnancy care, labor and delivery, chest/breast feeding supportive services, and postpartum support according to local standards of care in a gender- affirming way-
health care professionals educate transgender and gender diverse people undergoing gender-affirming treatment about the onset and time course of the physical changes induced by sex hormonal treatment-
health care professionals organize regular clinical evaluations for physical changes and potential adverse reactions to sex steroid hormones, including laboratory monitoring of sex steroid hormones every 3 months during the first year of hormone therapy or with dose changes until a stable adult dosing is reached followed by clinical and laboratory testing once or twice a year once an adult maintenance dose is attained-
translations of the soC focus on cross-cultural, conceptual, and literal equivalence to ensure alignment with the core principles that underpin the soC-8-
health care professionals consider gender-affirming medical interventions (hormonal treatment or surgery) for nonbinary people in the absence of "social gender transition-
health care professionals begin pubertal hormone suppression in eligible* transgender and gender diverse adolescents after they first exhibit physical changes of puberty ( tanner stage 2)-
medical providers discuss contraception metho | against using CEE when estradiol is an available treatment option-
institutional administrators, health care professionals, and other officials responsible for making housing decisions for tgd residents consider the individual’s housing preference, gender identity and expression, and safety considerations rather than solely their anatomy or sex assignment at birth-
health care providers understand the impact of social attitudes, laws, economic circumstances, and health systems on the lived experiences of transgender and gender diverse people worldwide-
health care professionals who are assessing eunuch individuals for treatment have demonstrated competency in assessing them-
institutional personnel allow tgd residents the private use of shower and toilet facilities upon request-
surgeons who perform gender-affirming surgical procedures have the following credentials:13-
following best practice guidelines for language translation to ensure high quality written resources are produced that are culturally and linguistically appropriate to the local situation-
HCPs discuss with their patients what language or terminology they prefer be used when referring to them-
health care professionals measure hormone levels during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at levels appropriate for the treatment goals of transgender and gender diverse people according to the tanner stage-
gender-affirming medical and surgical treatment (GAMST), only one letter of assessment from a member of the multidisciplinary team is needed-
patients who regret their gender-related surgical intervention be managed by an expert multidisciplinary team-
all institutional staff address tgd individuals by their chosen names and pronouns at all times-
health care professionals work with families, schools, and other relevant settings to promote acceptance of gender diverse expressions of behavior and identities of the adolescent-
HCPs offering consultation, psychotherapy, or both to gender diverse children and families/caregivers provide both par ties with age appropriate psycho-education about gender development-
health care professionals counsel transgender and gender diverse people that the use of antiretroviral medications is not a contraindication to gender-affirming hormone therapy-
health care professionals begin pubertal hormone suppression in eligible* transgender and gender diverse adolescents only after they first exhibit physical changes of puberty (Tanner stage 2)-
against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender and gender diverse people undergoing testosterone treatment and who have an otherwise average risk of malignancy-
health care professionals providing care for transgender youth and adults seek training and education in the aspects of intersex care relevant to their professional discipline-
health care professionals follow local breast cancer screening guidelines developed for cisgender women in their care of transgender and gender diverse people with breasts from natal puberty who have not had gender-affirming chest surgery-
health care professionals use GnRH agonists to suppress endogenous sex hor mones in eligible* transgender and gender diverse people for whom puberty blocking is indicated-
be enacted across the various relationships and settings in which a young person exists and functions-
health care professionals who are treating transgender and gender diverse people and prescribing or referring patients for hormone therapies/surgeries advise their patients about:a-
health care professionals who provide care to transgender and gender diverse people discuss the impact of gender-affirming treatments on sexual function, pleasure, and satisfaction-
their routine use in trans feminine populations-
all members of the health care workforce receive cultural-awareness training focused on treating transgender and gender diverse individuals with dignity during orientation and as part of annual or continuing education-
health care professionals and other users of the Standards of Care, Version 8 guidelines should apply the recommendations in ways that meet the needs of eunuch individuals-
surgeons consult a comprehensive, multidisciplinary team of professionals in the field of transgender health when eligible* transgender and gender diverse people request individually customized (previously termed "non-standard") surgeries as part of a gender-affirming surgical intervention-
health care professionals who provide care to transgender and gender diverse people offer the possibility of including the partner(s) in sexuality-related care, if appropriate-
health care professionals apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of transgender and gender diverse people who have the same risks-
health care professionals offering consultation, psychotherapy, or both to gender diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being-
health care professionals provide nonbinary people with individualized assessment and treatment that affirms their experience of gender-
gender-affirming medical and sur gical treatment (GAMST) for an adolescent, only one letter of assessment from a member of the multidisciplinary team is needed-
families be offered ongoing peer and professional psychosocial support (Hughes et al-
medical professionals charged with prescribing and monitoring hormones for tgd individuals living in institutions who need gender-affirming hormone therapy do so without undue delay and in accordance with the soC-8-
health care professionals consider gender-affirming surgical interventions in the absence of hormonal treatment, unless hormone therapy is required to achieve the desired surgical result-
health care professionals working with gender diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender diverse children-
health care professionals counsel individuals with intersexuality and their families about puberty suppression and/or hormonal treatment options within the context of the individual's gender identity, age, and unique medical circumstances-
health care professionals provide information to nonbinary people about the effects of hormonal therapies/surgery on future fertility and discuss the options for fertility preservation prior to starting hormonal treatment or undergoing surgery-
all personnel working in governmental, nongovernmental, and private agencies receive cultural-awareness training focused on treating transgender and gender diverse individuals with dignity and respect-
institutions involved in the training of health professionals develop competencies and learning objectives for transgender and gender diverse health within each of the competency areas for their specialty-
institutional personnel establish housing policies that ensure the safety of transgender and gender diverse residents without segregating or isolating these individuals-
that health care professionals conducting an assessment with gender diverse children consider relevant developmental factors, neurocognitive functioning and language skills-
health care professionals in transgender health inform transgender and gender diverse people commencing testosterone therapy of the potential and variable effects of this treatment on voice and communication-
all members of the health care workforce receive cultural-knowledge training focused on treating transgender and gender diverse individuals with dignity during orientation and as part of annual or continuing education-
the health care professionals working with gender diverse children receive training and have expertise in gender development and gender diversity in children and possess general knowledge of gender diversity across the life span-
voice and communication specialists assess current and desired vocal and communication function of transgender and gender diverse people and develop appropriate intervention plans for those dissatisfied with their voice and communication-
conjugated equine estrogens (CEEs) as a treatment option because blood levels of conjugated estrogens cannot be measured in transgender women making it difficult to prevent supraphysiologic dosing of estrogen and thereby increasing the potential risk of VTE (Hembree et al-
staff and professionals charged with providing health care to tgd individuals living in institutions recommend and support gender-affirming surgical treatments in accordance with the soC-8 when sought by the individual, without undue delay-
health care professionals conducting an assessment with gender diverse children consider relevant developmental factors, neurocognitive functioning, and language skills-
health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people-
health care professionals who provide care to transgender and gender diverse people acquire the knowledge and skills needed to address sexual health issues (relevant to their care provision)-
that health care professionals provide information to gender diverse children and their families/caregivers as the child approaches puberty about potential gender affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation-
mental health professionals offer care and support to transgender and gender diverse people to address mental health symptoms that interfere with a person’s capacity to participate in essential perioperative care before gender-affirmation surgery-
health care professionals offer cervical cancer screening to transgender and gender diverse people who currently have or previously had a cervix following local guidelines for cisgender women-
stopping the use of tobacco/nicotine prior to gender-affirmation surgery and abstaining from smoking up to several weeks postoperatively until the wound has completely healed (Matei & Danino, 2015)-
surgeons caring for transgender women and gender diverse people who have undergone vaginoplasty encourage follow-up with their primary surgeon, primary care physician, or gynecologist-
health care providers involve professionals from multiple disciplines who are experts in transgender health and in the management of the care of transgender and gender diverse adolescents-
health care professionals educate transgender and gender diverse people undergoing gender-affirming treatment about the onset and time course of physical changes induced by sex hormone treatment-
health care professionals counsel transgender and gender diverse people about the potential impact of stigma and trauma on sexual risk behavior, sexual avoidance, and sexual functioning-
administrators, health care professionals, and all others working in institutions charged with the responsibility of caring for tgd individuals allow those individuals who request appropriate clothing and grooming items to obtain such items concordant with their gender expression-
health care professionals in transgender health working with transgender and gender diverse people who are dissatisfied with their voice or communication consider offering a referral to voice and communication specialists for voice-related support, assessment, and training-
health care professionals assessing adults who wish to detransition and seek gender-related hormone intervention, surgical intervention, or both, utilize a comprehensive multidisciplinary assessment that will include additional viewpoints from experienced health care professional in transgender health and that considers, together with the individual, the role of social transition as part of the assessment process-
health care professionals assessing transgender and gender diverse adults for gender-affirming medical and surgical treatment:5-
health care professionals working with gender diverse children receive training and have expertise in gender development and gender diversity in children and possess a general knowledge of gender diversity across the life span-
the application of the Standards of Care (SOC) to people living in institutions as basic principles of health care and ethics (Beauchamp & Childress, 2019; Pope & Vasquez, 2016)-
its routine use-
health care professionals obtain a detailed medical history from transgender and gender diverse people, that includes past and present use of hormones, gonadal surgeries, as well as the presence of traditional cardiovascular and cerebrovascular risk factors with the aim of providing regular cardiovascular risk assessment according to established, locally used guidelines-
health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:6-
institutional administrators, health care professionals, and other officials responsible for making housing decisions for TGD residents consider the individual’s housing preference, gender identity and expression, and safety considerations, rather than solely their anatomy or sex assignment at birth-
testing be carried out every 3 months in the first year to allow some flexibility on the timing of these tests as there is no strong evidence or evidence from published studies supporting specific testing intervals-
health care professionals and other users of the s tandards of Care, Version 8 (soC-8) apply the recommendations in ways that meet the needs of local transgender and gender diverse communities, by providing culturally sensitive care that recognizes the realities of the countries they are practicing in-
health care professionals should not make it mandatory for transgender and gender diverse people to undergo psychotherapy prior to the initiation of gender-affirming treatment, while acknowledging psychotherapy may be helpful for some transgender and gender diverse people-
health care professionals discuss bone health with transgender and gender diverse people including the need for active weight bearing exercise, healthy diet, calcium, and vitamin d supplementation-
health care professionals working with gender diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum-
health care professionals consider gender-affirming surgical interventions in the absence of hormonal treatment unless hor mone therapy is required to achieve the desired surgical result-
health care professionals prescribe testosterone-lowering medications (either cyproterone acetate, spironolactone, or GnRH agonists) for eligible* transgender and gendered diverse people with testes taking estrogen as part of a hormonal treatment plan if their individual goal is to approximate levels of circulat ing sex hormone in cisgender women-
health care professionals counsel pre- or early-pubertal transgender and gender diverse youth seeking gender-affirming therapy and their families that currently evidence-based/established fertility preservation options are limited-
voice and communication specialists working with transgender and gender diverse people receive specific education to develop expertise in supporting vocal functioning, communication, and well-being in this population-
all personnel working in governmental, nongovernmental, and private agencies receive cultural-knowledge training focused on treating transgender and gender diverse individuals with dignity and respect-
scheduled risk assessments using a calculated prediction of ten-year total CVD risk based on risk prediction equations from large population samples-
health care providers involve professionals from multiple disciplines who are experts in transgender health and in the management of the care required for transgender and gender diverse adolescents-
health care professionals (HCPs) utilize local language and terms to deliver care in their specific cultural and/or geographical locale-
providers who offer pregnancy termination services ensure procedural approaches are gender-affirming and serve transgender people and those of diverse genders-
health care professionals who are prescribing or referring for hormonal therapies/surgeries counsel individuals with intersexuality and fertility potential and their families about a) known effects of hormonal therapies/surgery on future fertility; b) potential effects of therapies that are not well studied and are of unknown reversibility; c) fertility preservation options; and d) psychosocial implications of infertility-
health care professionals obtain a detailed medical history from transgender and gender diverse people that includes past and present use of hormones, gonadal surgeries as well as the presence of traditional osteoporosis risk factors, to assess the optimal age and necessity for osteoporosis screening-
when significant mental health symptoms or substance abuse exists, mental health professionals assess the potential negative impact mental health symptoms may have on outcomes based on the nature of the specific gender-affirming surgical procedure-
surgery be offered to very young children (American Urological Association, 2019; Pediatric Endocrine Society, 2020)-
providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding-
health care professionals responsible for providing gender-affirming care to individuals residing in institutions (or associated with institutions or agencies) recognize the entire list of recommendations of the SOC-8, apply equally to TGD people living in institutions-
voice and communication specialists assess current and desired vocal and Statements of Recommendations14-
health care professionals working with transgender and gender diverse people who are considering undergoing voice surgery consider offering a referral to a voice and communication specialist who can provide pre- and/or postoperative support-
"reparative" and "conversion" therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered-
surgical outcomes be tracked and communicated to the patients as part of the informed consent (Schechter et al-
transgender and gender diverse people with a uterus who wish to carry a pregnancy undergo preconception care and prenatal counseling regarding the use and cessation of gender-affirming hormones, pregnancy care, labor and delivery, chest/breast feeding supportive services, and postpartum support according to local standards of care in a gender- affirming way-
health care professionals educate transgender and gender diverse people undergoing gender-affirming treatment about the onset and time course of the physical changes induced by sex hormonal treatment-
health care professionals organize regular clinical evaluations for physical changes and potential adverse reactions to sex steroid hormones, including laboratory monitoring of sex steroid hormones every 3 months during the first year of hormone therapy or with dose changes until a stable adult dosing is reached followed by clinical and laboratory testing once or twice a year once an adult maintenance dose is attained-
translations of the soC focus on cross-cultural, conceptual, and literal equivalence to ensure alignment with the core principles that underpin the soC-8-
health care professionals consider gender-affirming medical interventions (hormonal treatment or surgery) for nonbinary people in the absence of "social gender transition-
health care professionals begin pubertal hormone suppression in eligible* transgender and gender diverse adolescents after they first exhibit physical changes of puberty ( tanner stage 2)-
medical providers discuss contraception metho |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>What are the recommendations in data_sources/ppacacon.pdf [/INST] | appropriation levels for programs under this title, except for programs under part C or D-
changes in such policies, including necessary changes in the provisions of law which govern the way in which the CLASS Independence Fund is to be managed-
appropriation levels for programs under this part-
for designation as the CLASS Independence Benefit Plan for offering to the public the plan that the Council determines best balances price and bene-fits to meet enrollees’ needs in an actuarially sound man-ner, while optimizing the probability of the long-term sus-tainability of the CLASS program-
to the Commission the inclusion of other topics for health care workforce development areas that require special attention-
that such program be so established, on appropriate procedures and mechanisms for such establishment; and (C) for such legislation and administrative action as the Secretary determines appropriate-
a single set of operating rules per transaction standard and maintain the goal of creating as much uni-formity as possible in the implementation of the electronic standards-
ways to address such barriers; and (5) encourages innovations to address population needs, constant changes in technology, and other environmental fac-tors | appropriation levels for programs under this title, except for programs under part C or D-
changes in such policies, including necessary changes in the provisions of law which govern the way in which the CLASS Independence Fund is to be managed-
appropriation levels for programs under this part-
for designation as the CLASS Independence Benefit Plan for offering to the public the plan that the Council determines best balances price and bene-fits to meet enrollees’ needs in an actuarially sound man-ner, while optimizing the probability of the long-term sus-tainability of the CLASS program-
to the Commission the inclusion of other topics for health care workforce development areas that require special attention-
that such program be so established, on appropriate procedures and mechanisms for such establishment; and (C) for such legislation and administrative action as the Secretary determines appropriate-
a single set of operating rules per transaction standard and maintain the goal of creating as much uni-formity as possible in the implementation of the electronic standards-
ways to address such barriers; and (5) encourages innovations to address population needs, constant changes in technology, and other environmental fac-tors |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were In response to the request for speech therapy for a two-year-old male enrollee with autism, the internal reviewer determined that speech therapy is widely accepted as standard treatment for individuals with autism and can improve language and functional skills. The patient's deficiencies in pragmatic language, behavior, and cognition, rather than educationally-based, have affected their ability to perform everyday activities such as dressing, bathing, and using utensils. This represents a detriment to their quality of life. This patient previously used a spoon and made requests but now has difficulty with these activities. Patients with acquired brain injury receive speech therapy as standard care to address cognitive and language deficits, not related to laryngeal pathology or swallowing dysfunction. The patient's needs are akin to those of patients with acquired brain injury, warranting consideration for speech therapy. Accordingly, the internal reviewer determined that the requested speech therapy services are medically necessary for the treatment of the patient's medical condition. The decision to deny the services should be reconsidered.[/INST] | The treatment is considered medically necessary because the I regressed from using a spoon and making requests to being unable to perform activities of daily living. | The treatment is considered medically necessary because the I regressed from using a spoon and making requests to being unable to perform activities of daily living. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were In response to the request for speech therapy for a two-year-old male enrollee with autism, the internal reviewer determined that speech therapy is widely accepted as standard treatment for individuals with autism and can improve language and functional skills. The patient's deficiencies in pragmatic language, behavior, and cognition, rather than educationally-based, have affected their ability to perform everyday activities such as dressing, bathing, and using utensils. This represents a detriment to their quality of life. This patient previously used a spoon and made requests but now has difficulty with these activities. Patients with acquired brain injury receive speech therapy as standard care to address cognitive and language deficits, not related to laryngeal pathology or swallowing dysfunction. The patient's needs are akin to those of patients with acquired brain injury, warranting consideration for speech therapy. Accordingly, the internal reviewer determined that the requested speech therapy services are medically necessary for the treatment of the patient's medical condition. The decision to deny the services should be reconsidered.[/INST] | Grounds for Appeal:
On behalf of my parent, we are appealing the Health Plan's denial of speech therapy services for their two-year-old male enrollee with autism. We believe that the requested services are medically necessary for treatment of my medical condition.
The literature demonstrates that speech therapy is well established as a standard treatment for Is with autism and can provide benefit in terms of language and function. My deficits in pragmatic language, behavior, and cognition affect functional skills regarding daily living activities, such as dressing and bathing. Ihas regressed from using a spoon and making requests to being unable to perform these activities, which is a functional deficit that requires treatment.
Patients with acquired brain injuries receive speech therapy as a standard of care for cognition and language skills to address functional deficits not related to laryngeal pathology or swallowing dysfunction. We believe that Is with autism have similar needs and are likely to benefit from individual speech therapy.
Therefore, we request that the Health Plan reinstate the requested speech therapy services for my treatment. | Grounds for Appeal:
On behalf of my parent, we are appealing the Health Plan's denial of speech therapy services for their two-year-old male enrollee with autism. We believe that the requested services are medically necessary for treatment of my medical condition.
The literature demonstrates that speech therapy is well established as a standard treatment for Is with autism and can provide benefit in terms of language and function. My deficits in pragmatic language, behavior, and cognition affect functional skills regarding daily living activities, such as dressing and bathing. Ihas regressed from using a spoon and making requests to being unable to perform these activities, which is a functional deficit that requires treatment.
Patients with acquired brain injuries receive speech therapy as a standard of care for cognition and language skills to address functional deficits not related to laryngeal pathology or swallowing dysfunction. We believe that Is with autism have similar needs and are likely to benefit from individual speech therapy.
Therefore, we request that the Health Plan reinstate the requested speech therapy services for my treatment. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review has found that a 44-year-old female enrollee meets the criteria for weight loss surgery as set by the National Institutes of Health consensus statements, but her body mass index is greater than 50. While pre-operative diet and exercise plans may have some impact on weight loss, there is no scientific evidence to support their effectiveness in predicting or improving the outcomes of weight loss surgery. The review also highlights that weight loss surgical procedures, such as metabolic surgery, have been shown to offer a better outcome for the treatment of diabetes than medical regimens. The grounds for our denial of this request are based on medical necessity.[/INST] | The treatment is considered medically necessary because the I has a body mass index of greater than 50, which qualifies her for weight loss surgery according to the National Institutes of Health consensus statements. The physician reviewer found that there is no evidence to suggest that pre-operative diet and exercise plans can predict or improve the outcomes of weight loss surgery. However, noted that weight loss surgical procedures, such as Roux-en-Y gastric bypass, have been shown to significantly improve the management of co-morbidities like diabetes, compared to medical regimens alone. As a result, the treatment was considered necessary for my overall health and well-being. | The treatment is considered medically necessary because the I has a body mass index of greater than 50, which qualifies her for weight loss surgery according to the National Institutes of Health consensus statements. The physician reviewer found that there is no evidence to suggest that pre-operative diet and exercise plans can predict or improve the outcomes of weight loss surgery. However, noted that weight loss surgical procedures, such as Roux-en-Y gastric bypass, have been shown to significantly improve the management of co-morbidities like diabetes, compared to medical regimens alone. As a result, the treatment was considered necessary for my overall health and well-being. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review has found that a 44-year-old female enrollee meets the criteria for weight loss surgery as set by the National Institutes of Health consensus statements, but her body mass index is greater than 50. While pre-operative diet and exercise plans may have some impact on weight loss, there is no scientific evidence to support their effectiveness in predicting or improving the outcomes of weight loss surgery. The review also highlights that weight loss surgical procedures, such as metabolic surgery, have been shown to offer a better outcome for the treatment of diabetes than medical regimens. The grounds for our denial of this request are based on medical necessity.[/INST] | Ms. [Last Name],
We are writing to appeal for the Roux-en-Y gastric bypass surgery for Mr. [First Name]. Ms. [First Name] has a severe case of morbid obesity, which has led to numerous health complications and reduced overall well-being.
According to our independent medical review, Ms. [First Name] meets the criteria for weight loss surgery as set by the National Institutes of Health consensus statements. Her body mass index (BMI) is over 50, placing her in the highest risk category for obesity-related health issues. We understand that there is no scientific evidence to suggest that pre-operative diet and exercise plans can improve or predict the outcomes of weight loss surgery. However, we do have evidence to support the use of weight loss surgical procedures (metabolic surgery) in the management of co-morbidities such as diabetes. Sjostrom and colleagues have demonstrated that metabolic surgery often provides better outcomes than any medical regimens for the treatment of diabetes.
We are confident that the Roux-en-Y gastric bypass surgery would be a medical necessity for Ms. [Last Name], as it would significantly improve her quality of life and reduce her risk of obesity-related health complications. We believe that this surgery is covered by her health insurance plan, and we urge them to approve the request immediately.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Ms. [Last Name],
We are writing to appeal for the Roux-en-Y gastric bypass surgery for Mr. [First Name]. Ms. [First Name] has a severe case of morbid obesity, which has led to numerous health complications and reduced overall well-being.
According to our independent medical review, Ms. [First Name] meets the criteria for weight loss surgery as set by the National Institutes of Health consensus statements. Her body mass index (BMI) is over 50, placing her in the highest risk category for obesity-related health issues. We understand that there is no scientific evidence to suggest that pre-operative diet and exercise plans can improve or predict the outcomes of weight loss surgery. However, we do have evidence to support the use of weight loss surgical procedures (metabolic surgery) in the management of co-morbidities such as diabetes. Sjostrom and colleagues have demonstrated that metabolic surgery often provides better outcomes than any medical regimens for the treatment of diabetes.
We are confident that the Roux-en-Y gastric bypass surgery would be a medical necessity for Ms. [Last Name], as it would significantly improve her quality of life and reduce her risk of obesity-related health complications. We believe that this surgery is covered by her health insurance plan, and we urge them to approve the request immediately.
Thank you for your attention to this matter.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for Supartz injections provided by Torrance Memorial Physicians and prospective authorization and coverage for future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee.
An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The conclusive evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patients options were limited, as she did not respond to other conservative treatment, including medication, bracing, and activity modification. Therefore, Supartz injections provided by Torrance Memorial Physicians and future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee were and are medically necessary for the treatment of this patient.
Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Insurance Denial should stand.
Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.[/INST] | An independent medical review has found that the I has been provided with reimbursement for Supartz injections by Torrance Memorial Physicians and prospective authorization for future treatment with hyaluronan injection(s) between Supartz injections or Monovisc injections in the left knee. Due to mixed results from current medical literature, the review recommends that viscosupplementation should only be recommended for individuals with a history of last benefit from prior injections and in extremely limited situations where all other treatment options have been exhausted.
Since this I has not responded to other conservative treatments, including medication, bracing, and activity modification, viscosupplementation is deemed medically necessary for her treatment. The review also indicates that there are limited conclusive evidence regarding viscosupplementation.
The reviewer, being board certified in orthopedic surgery and having recent or current clinical experience treating individuals with similar medical condition, has determined that the services are medically necessary for treatment of my condition. The Health Plans denial should be overturned.
It is important to note that in this case, the doctor's office or medical records are unavailable. Therefore, the information provided in the final result is from 's manual and deemed reliable for this specific case. The healthcare provider should contact the insurance company to present the same information to fit the case. | An independent medical review has found that the I has been provided with reimbursement for Supartz injections by Torrance Memorial Physicians and prospective authorization for future treatment with hyaluronan injection(s) between Supartz injections or Monovisc injections in the left knee. Due to mixed results from current medical literature, the review recommends that viscosupplementation should only be recommended for individuals with a history of last benefit from prior injections and in extremely limited situations where all other treatment options have been exhausted.
Since this I has not responded to other conservative treatments, including medication, bracing, and activity modification, viscosupplementation is deemed medically necessary for her treatment. The review also indicates that there are limited conclusive evidence regarding viscosupplementation.
The reviewer, being board certified in orthopedic surgery and having recent or current clinical experience treating individuals with similar medical condition, has determined that the services are medically necessary for treatment of my condition. The Health Plans denial should be overturned.
It is important to note that in this case, the doctor's office or medical records are unavailable. Therefore, the information provided in the final result is from 's manual and deemed reliable for this specific case. The healthcare provider should contact the insurance company to present the same information to fit the case. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for Supartz injections provided by Torrance Memorial Physicians and prospective authorization and coverage for future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee.
An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The conclusive evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases where everything else has been tried and the options are limited. In this case, the patients options were limited, as she did not respond to other conservative treatment, including medication, bracing, and activity modification. Therefore, Supartz injections provided by Torrance Memorial Physicians and future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee were and are medically necessary for the treatment of this patient.
Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Insurance Denial should stand.
Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.[/INST] | The treatment is considered medically necessary because the enrollee had reimbursement for Supartz injections and prospective authorization and coverage for future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee. The mixed results from current medical literature regarding viscosupplementation in treating osteoarthritis being uncomfortable, and no conclusive evidence provided by the American Academy of Orthopedic Surgeons, viscosupplementation is only recommended in limited situations, when everything else has been tried and the options are limited, as it was in this case for the enrollee who did not respond to other conservative treatment. The review determined that Supartz injections provided by Torrance Memorial Physicians and future treatment with hyaluronan injection(s) were medically necessary for the treatment of my medical condition. | The treatment is considered medically necessary because the enrollee had reimbursement for Supartz injections and prospective authorization and coverage for future treatment with hyaluronan injection(s) (series of Supartz injections or Monovisc injection) in the left knee. The mixed results from current medical literature regarding viscosupplementation in treating osteoarthritis being uncomfortable, and no conclusive evidence provided by the American Academy of Orthopedic Surgeons, viscosupplementation is only recommended in limited situations, when everything else has been tried and the options are limited, as it was in this case for the enrollee who did not respond to other conservative treatment. The review determined that Supartz injections provided by Torrance Memorial Physicians and future treatment with hyaluronan injection(s) were medically necessary for the treatment of my medical condition. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Upon request, the internal medical review has found that the parent of a 10-year-old male enrollee with autism has requested speech therapy services for treatment of his condition. we examining this request has determined that laryngeal/oropharyngeal anatomical abnormalities are not required for abnormal language development in children with developmental delay of speech and language, and that plasticity in the developing brain still exists despite underlying neurological disease. Specifically, speech therapy can be utilized to induce brain plasticity, helping to retrain neural circuitry not compromised by the underlying pathogenetic processes that cause expressive and receptive speech delay. Following a thorough review of the available medical literature, it has been determined that speech therapy is a necessary intervention for the treatment of patients diagnosed with autism spectrum disorders. The patient's request for speech therapy will be granted as medically necessary.[/INST] | On behalf of I, I am appealing the independent medical review finding that speech therapy services are not medically necessary for the treatment of his autism spectrum disorder. The review is based on the assumption that laryngeal/oropharyngeal anatomical abnormalities are necessary for abnormal language development in children with developmental delay of speech and language. However, according to medical literature, plasticity in the developing brain exists despite the presence of underlying neurologic disease, and speech therapy can be used to improve overall neurologic health. Furthermore, studies have shown that speech therapy is a medically necessary intervention for Is diagnosed with autism spectrum disorders, helping to induce brain plasticity and retraining of neural circuitry that may be compromised by the underlying pathogenetic processes. I urge to consider the available evidence and base their finding on accurate medical information. | On behalf of I, I am appealing the independent medical review finding that speech therapy services are not medically necessary for the treatment of his autism spectrum disorder. The review is based on the assumption that laryngeal/oropharyngeal anatomical abnormalities are necessary for abnormal language development in children with developmental delay of speech and language. However, according to medical literature, plasticity in the developing brain exists despite the presence of underlying neurologic disease, and speech therapy can be used to improve overall neurologic health. Furthermore, studies have shown that speech therapy is a medically necessary intervention for Is diagnosed with autism spectrum disorders, helping to induce brain plasticity and retraining of neural circuitry that may be compromised by the underlying pathogenetic processes. I urge to consider the available evidence and base their finding on accurate medical information. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Upon request, the internal medical review has found that the parent of a 10-year-old male enrollee with autism has requested speech therapy services for treatment of his condition. we examining this request has determined that laryngeal/oropharyngeal anatomical abnormalities are not required for abnormal language development in children with developmental delay of speech and language, and that plasticity in the developing brain still exists despite underlying neurological disease. Specifically, speech therapy can be utilized to induce brain plasticity, helping to retrain neural circuitry not compromised by the underlying pathogenetic processes that cause expressive and receptive speech delay. Following a thorough review of the available medical literature, it has been determined that speech therapy is a necessary intervention for the treatment of patients diagnosed with autism spectrum disorders. The patient's request for speech therapy will be granted as medically necessary.[/INST] | The treatment is considered medically necessary because the parent of the 10-year-old male enrollee has requested speech therapy services for the treatment of his autism. The physician reviewer found that laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. The ultimate goal of this treatment is to induce brain plasticity, with the aim of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. The review of available peer-reviewed medical literature indicates that speech therapy is a medically necessary intervention for the treatment of Is diagnosed with autism spectrum disorders. | The treatment is considered medically necessary because the parent of the 10-year-old male enrollee has requested speech therapy services for the treatment of his autism. The physician reviewer found that laryngeal/oropharyngeal or anatomical abnormalities are not necessary for abnormal language development in children with developmental delay of speech and language. The literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. The ultimate goal of this treatment is to induce brain plasticity, with the aim of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. The review of available peer-reviewed medical literature indicates that speech therapy is a medically necessary intervention for the treatment of Is diagnosed with autism spectrum disorders. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
An internal review was conducted regarding a 22-year-old female enrollee's request for authorization and coverage for gastric bypass surgery. The review determined that the requested procedure is not medically necessary for the treatment of the enrollee's morbid obesity.
A reviewer within the organization overturned the initial denial, citing medical necessity as the reason for their decision. Specifically, the grounds for the reversal were based on medical necessity.[/INST] | Dear Health Plan Appeals,
I am writing to you on behalf of [Patient Name], a 22-year-old enrollee in your plan. Recently, [Patient Name] submitted a request for authorization and coverage for gastric bypass surgery. Unfortunately, your plan denied the request, stating that the requested procedure is medically necessary for the treatment of [Patient Name]'s morbid obesity.
I have reviewed the medical necessity evidence submitted by [Patient Name]'s physician. After careful consideration, the medical necessity review panel has overturned your denial of [Patient Name]'s request for gastric bypass surgery.
We believe that the requested procedure is medically necessary for [Patient Name], and we base our determination on the following grounds:
[Insert further details on the medical grounds here].
We understand that our decision may differ from your previous determination. However, we believe that our decision is in line with best medical practices and decisions made by other healthcare providers for Is in similar situations.
Please approve [Patient Name]'s request for gastric bypass surgery and provide coverage for the procedure.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Dear Health Plan Appeals,
I am writing to you on behalf of [Patient Name], a 22-year-old enrollee in your plan. Recently, [Patient Name] submitted a request for authorization and coverage for gastric bypass surgery. Unfortunately, your plan denied the request, stating that the requested procedure is medically necessary for the treatment of [Patient Name]'s morbid obesity.
I have reviewed the medical necessity evidence submitted by [Patient Name]'s physician. After careful consideration, the medical necessity review panel has overturned your denial of [Patient Name]'s request for gastric bypass surgery.
We believe that the requested procedure is medically necessary for [Patient Name], and we base our determination on the following grounds:
[Insert further details on the medical grounds here].
We understand that our decision may differ from your previous determination. However, we believe that our decision is in line with best medical practices and decisions made by other healthcare providers for Is in similar situations.
Please approve [Patient Name]'s request for gastric bypass surgery and provide coverage for the procedure.
Thank you for your attention to this matter.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
An internal review was conducted regarding a 22-year-old female enrollee's request for authorization and coverage for gastric bypass surgery. The review determined that the requested procedure is not medically necessary for the treatment of the enrollee's morbid obesity.
A reviewer within the organization overturned the initial denial, citing medical necessity as the reason for their decision. Specifically, the grounds for the reversal were based on medical necessity.[/INST] | The treatment is considered medically necessary because it was thought to be an appropriate treatment for the enrollee's morbid obesity based on current medical standards and guidelines. | The treatment is considered medically necessary because it was thought to be an appropriate treatment for the enrollee's morbid obesity based on current medical standards and guidelines. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Based on the internal medical review findings, the parent of an enrollee has requested pelvic floor physical therapy for treatment of the enrollees medical condition. The review found that pelvic floor physical therapy has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. However, as it is challenging to accurately diagnose specific types of constipation in the pediatric population, empiric approaches for treatment may be appropriate and reasonable. Pelvic floor training is both appropriate and likely to yield a positive outcome for treatment of the patients encopresis. Therefore, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. However, it has been determined that this request falls under the experimental/investigational category, so the Health Plan's denial sh[/INST] | The three physician reviewers found that pelvic floor physical therapy was established as likely to be more beneficial for treating the enrollee's medical condition than any available standard therapy. They noted that constipation in the pediatric population with behavioral issues can be challenging to diagnose and that empiric approaches for treatment may be necessary. Pelvic floor physical therapy was deemed appropriate and likely to yield a positive outcome for treatment of the child's encopresis. The reviewers were Board-certified in pediatric gastroenterology, with expertise in the treatment of the child's medical condition and relevant clinical experience through recent or current clinical practice treating children with the same or a similar medical condition. The treatment was not considered medically necessary as it was experimental/investigational. | The three physician reviewers found that pelvic floor physical therapy was established as likely to be more beneficial for treating the enrollee's medical condition than any available standard therapy. They noted that constipation in the pediatric population with behavioral issues can be challenging to diagnose and that empiric approaches for treatment may be necessary. Pelvic floor physical therapy was deemed appropriate and likely to yield a positive outcome for treatment of the child's encopresis. The reviewers were Board-certified in pediatric gastroenterology, with expertise in the treatment of the child's medical condition and relevant clinical experience through recent or current clinical practice treating children with the same or a similar medical condition. The treatment was not considered medically necessary as it was experimental/investigational. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Based on the internal medical review findings, the parent of an enrollee has requested pelvic floor physical therapy for treatment of the enrollees medical condition. The review found that pelvic floor physical therapy has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. However, as it is challenging to accurately diagnose specific types of constipation in the pediatric population, empiric approaches for treatment may be appropriate and reasonable. Pelvic floor training is both appropriate and likely to yield a positive outcome for treatment of the patients encopresis. Therefore, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. However, it has been determined that this request falls under the experimental/investigational category, so the Health Plan's denial sh[/INST] | Dear Health Plan Administrator,
Ihe parent of an enrollee who has a medical condition of encopresis, which requires pelvic floor physical therapy treatment. The parent has requested this therapy, and I am writing to appeal the denial of the requested therapy.
After reviewing the independent medical review findings, a consensus was reached among three physician reviewers that pelvic floor physical therapy is likely to be more beneficial for treatment of my medical condition than any available standard therapy. The three reviewers, who are board certified in pediatric gastroenterology and have current clinical experience treating Is with similar medical conditions, identified specific types of constipation in this case as difficult to diagnose in the pediatric population. Therefore, an empirical approach to treatment becomes reasonable and appropriate. The consensus among s is that pelvic floor physical therapy is both appropriate and likely to yield a positive outcome for treatment of my encopresis, making it more beneficial than any available standard therapy.
We request that the denial of the requested therapy be overturned and the requested therapy be approved.
Sincerely,
[Your Name] | Dear Health Plan Administrator,
Ihe parent of an enrollee who has a medical condition of encopresis, which requires pelvic floor physical therapy treatment. The parent has requested this therapy, and I am writing to appeal the denial of the requested therapy.
After reviewing the independent medical review findings, a consensus was reached among three physician reviewers that pelvic floor physical therapy is likely to be more beneficial for treatment of my medical condition than any available standard therapy. The three reviewers, who are board certified in pediatric gastroenterology and have current clinical experience treating Is with similar medical conditions, identified specific types of constipation in this case as difficult to diagnose in the pediatric population. Therefore, an empirical approach to treatment becomes reasonable and appropriate. The consensus among s is that pelvic floor physical therapy is both appropriate and likely to yield a positive outcome for treatment of my encopresis, making it more beneficial than any available standard therapy.
We request that the denial of the requested therapy be overturned and the requested therapy be approved.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The parent of an enrollee has requested reimbursement for corneal collagen cross-linking. However, based on our internal review, the medical evidence does not support the services at issue in this clinical setting. While there is evidence to suggest that corneal collagen cross-linking can be effective for stabilizing corneal ectasia, it should not be considered a standard therapy for the patient's medical condition of corneal ectasia. Our review did not find that corneal collagen cross-linking fulfilled an unmet need for this condition, and we believe that there are other treatment options available that may be more effective. Therefore, the Health Plan denial should be upheld for this experimental/investigational treatment.[/INST] | Dear Health Plan,
I am appealing the denial of coverage for corneal collagen cross-linking for my enrollee, who has been diagnosed with corneal ectasia. After an independent medical review, it was determined that corneal collagen cross-linking was the most effective treatment available for my medical condition based on their vision loss and progression.
Physician reviewers, who are board certified in ophthalmology and actively practicing, determined that corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. This treatment fulfills an unmet need, as there are no other treatment options available to slow or halt disease progression. Therefore, corneal collagen cross-linking was likely to have been more efficacious than other treatment options.
I request that you overturn the denial of coverage for this medical service on behalf of my enrollee.
Sincerely, [Your Name] | Dear Health Plan,
I am appealing the denial of coverage for corneal collagen cross-linking for my enrollee, who has been diagnosed with corneal ectasia. After an independent medical review, it was determined that corneal collagen cross-linking was the most effective treatment available for my medical condition based on their vision loss and progression.
Physician reviewers, who are board certified in ophthalmology and actively practicing, determined that corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. This treatment fulfills an unmet need, as there are no other treatment options available to slow or halt disease progression. Therefore, corneal collagen cross-linking was likely to have been more efficacious than other treatment options.
I request that you overturn the denial of coverage for this medical service on behalf of my enrollee.
Sincerely, [Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The parent of an enrollee has requested reimbursement for corneal collagen cross-linking. However, based on our internal review, the medical evidence does not support the services at issue in this clinical setting. While there is evidence to suggest that corneal collagen cross-linking can be effective for stabilizing corneal ectasia, it should not be considered a standard therapy for the patient's medical condition of corneal ectasia. Our review did not find that corneal collagen cross-linking fulfilled an unmet need for this condition, and we believe that there are other treatment options available that may be more effective. Therefore, the Health Plan denial should be upheld for this experimental/investigational treatment.[/INST] | An independent medical review found that corneal collagen cross-linking was medically necessary for the treatment of an enrollee's corneal ectasia. The treatment fulfills an unmet need, as there is a lack of other treatment options available to slow or halt disease progression. The reviewers determined that the proposed treatment was likely to be more effective than standard therapy and overturned the health plan's denial. The reviewers were board certified in ophthalmology, had recent or current clinical experience treating corneal ectasias, and were experts in the treatment of the enrollee's medical condition. The review found that the treatment was experimental/investigational. | An independent medical review found that corneal collagen cross-linking was medically necessary for the treatment of an enrollee's corneal ectasia. The treatment fulfills an unmet need, as there is a lack of other treatment options available to slow or halt disease progression. The reviewers determined that the proposed treatment was likely to be more effective than standard therapy and overturned the health plan's denial. The reviewers were board certified in ophthalmology, had recent or current clinical experience treating corneal ectasias, and were experts in the treatment of the enrollee's medical condition. The review found that the treatment was experimental/investigational. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Original insurance denial:
Dear [Enrollment],
After reviewing your claim for the inpatient level of care requested by a 28-year-old female enrollee for treatment of her L1 compression fracture, our internal medical review found that consistent with the medical literature, significant ligamentous spinal injuries are an absolute indication for surgical repair as there is a high chance for gibbous deformity, instability, and nonunion in the ligamentous injury group (Vaccaro, et al). Although most fractures at the thoracolumbar level do not require surgery, the exception is the fracture associated with significant ligamentous disruption. The surgeon's operative note in this patient's case documented significant ligamentous disruption, therefore the surgery was clinically indicated.
Our review also noted that the patient had significant assistance for mobility upon discharge. Given the severity of the patient's injury and surgical repair, the continued inpatient level of care was medically necessary during the said timeframe.
However, we have determined that the services requested are not covered under your insurance plan. We apologize for any inconvenience this may cause you. If you have any further questions or concerns, please don't hesitate to contact us.
Sincerely,
[Your insurance provider][/INST] | The treatment is considered medically necessary due to the severity of my injury, which caused a significant ligamentous disruption at the thoracolumbar level. This required surgical repair to avoid gibbous deformity, instability, and nonunion. Despite most fractures at this level not requiring surgery, the exception is for fractures associated with significant ligamentous disruption. My need for significant assistance for mobility and the extension of stay in the hospital were also factors in determining the medical necessity of this treatment. | The treatment is considered medically necessary due to the severity of my injury, which caused a significant ligamentous disruption at the thoracolumbar level. This required surgical repair to avoid gibbous deformity, instability, and nonunion. Despite most fractures at this level not requiring surgery, the exception is for fractures associated with significant ligamentous disruption. My need for significant assistance for mobility and the extension of stay in the hospital were also factors in determining the medical necessity of this treatment. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Original insurance denial:
Dear [Enrollment],
After reviewing your claim for the inpatient level of care requested by a 28-year-old female enrollee for treatment of her L1 compression fracture, our internal medical review found that consistent with the medical literature, significant ligamentous spinal injuries are an absolute indication for surgical repair as there is a high chance for gibbous deformity, instability, and nonunion in the ligamentous injury group (Vaccaro, et al). Although most fractures at the thoracolumbar level do not require surgery, the exception is the fracture associated with significant ligamentous disruption. The surgeon's operative note in this patient's case documented significant ligamentous disruption, therefore the surgery was clinically indicated.
Our review also noted that the patient had significant assistance for mobility upon discharge. Given the severity of the patient's injury and surgical repair, the continued inpatient level of care was medically necessary during the said timeframe.
However, we have determined that the services requested are not covered under your insurance plan. We apologize for any inconvenience this may cause you. If you have any further questions or concerns, please don't hesitate to contact us.
Sincerely,
[Your insurance provider][/INST] | Dear Seeking Health Coverage,
I am writing to request continuation of inI level of care for treatment of my L1 compression fracture status post fall off a horse.
As per the independent medical review findings, significant ligamentous spinal injuries are an absolute indication for surgical repair as there is a high chance for gibbous deformity, instability, and nonunion in the ligamentous injury group (Vaccaro, et al). My case, as documented by the surgeons operative note, also involved significant ligamentous disruption.
Given the severity of my injury and surgical repair, I believe that the continued inI level of care was medically necessary during the said timeframe. Therefore, I am requesting that my insurance plan cover the costs of my continued inI care.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Dear Seeking Health Coverage,
I am writing to request continuation of inI level of care for treatment of my L1 compression fracture status post fall off a horse.
As per the independent medical review findings, significant ligamentous spinal injuries are an absolute indication for surgical repair as there is a high chance for gibbous deformity, instability, and nonunion in the ligamentous injury group (Vaccaro, et al). My case, as documented by the surgeons operative note, also involved significant ligamentous disruption.
Given the severity of my injury and surgical repair, I believe that the continued inI level of care was medically necessary during the said timeframe. Therefore, I am requesting that my insurance plan cover the costs of my continued inI care.
Thank you for your attention to this matter.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The insurance denied the request for wireless capsule endoscopy coverage due to the study summary being experimental and investigational. The enrollee was seeking authorization for the procedure to evaluate Crohn's disease, ulcer, and diarrhea. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohn's disease. wes found that capsule endoscopy is useful for diagnosing Crohn's disease, even if imaging tests such as small bowel follow-through and ileoscopy were negative or unsuccessful. The reviewers also noted that capsule endoscopy has proven to be more sensitive in the detection of small bowel Crohn's disease than alternatives such as CT scans, small bowel follow-through, and enteroclysis. However, the reviewers still concluded that the requested diagnostic procedure was experimental/investigational and therefore, the denied coverage. The reviewers had board certification in internal medicine with sub-specialty certification in gastroenterology and had significant past clinical experience treating patients with similar medical conditions.[/INST] | Dear Health Plan,
I am writing to appeal your denial of authorization and coverage for wireless capsule endoscopy for evaluation of Crohn's disease, ulcer and diarrhea. The independent medical review found that the physician reviewers determined that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohn's disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohn's disease even if imaging tests such as small bowel follow-through and ileoscopy are negative or unsuccessful. Capsule endoscopy has been proven to be more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis, and capsule endoscopy resulted in a change in management in a significant number of Is based on findings missed by other tests.
Two of three reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the Is medical condition than any available standard therapy. For these reasons, I believe that this procedure is necessary for a complete evaluation and management of my Crohn's disease, ulcer and diarrhea and the requested wireless capsule endoscopy is likely to provide useful diagnostic information in this case and would be more beneficial for the I than any available standard therapy.
Please let me know if you require any additional information to support this appeal.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Dear Health Plan,
I am writing to appeal your denial of authorization and coverage for wireless capsule endoscopy for evaluation of Crohn's disease, ulcer and diarrhea. The independent medical review found that the physician reviewers determined that current American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohn's disease. Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohn's disease even if imaging tests such as small bowel follow-through and ileoscopy are negative or unsuccessful. Capsule endoscopy has been proven to be more sensitive in the detection of small bowel Crohns disease than alternatives such as CT scan, small bowel follow-through, and enteroclysis, and capsule endoscopy resulted in a change in management in a significant number of Is based on findings missed by other tests.
Two of three reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the Is medical condition than any available standard therapy. For these reasons, I believe that this procedure is necessary for a complete evaluation and management of my Crohn's disease, ulcer and diarrhea and the requested wireless capsule endoscopy is likely to provide useful diagnostic information in this case and would be more beneficial for the I than any available standard therapy.
Please let me know if you require any additional information to support this appeal.
Thank you for your attention to this matter.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The insurance denied the request for wireless capsule endoscopy coverage due to the study summary being experimental and investigational. The enrollee was seeking authorization for the procedure to evaluate Crohn's disease, ulcer, and diarrhea. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for endoscopy in inflammatory bowel disease recommend the use of capsule endoscopy in the diagnosis of Crohn's disease. wes found that capsule endoscopy is useful for diagnosing Crohn's disease, even if imaging tests such as small bowel follow-through and ileoscopy were negative or unsuccessful. The reviewers also noted that capsule endoscopy has proven to be more sensitive in the detection of small bowel Crohn's disease than alternatives such as CT scans, small bowel follow-through, and enteroclysis. However, the reviewers still concluded that the requested diagnostic procedure was experimental/investigational and therefore, the denied coverage. The reviewers had board certification in internal medicine with sub-specialty certification in gastroenterology and had significant past clinical experience treating patients with similar medical conditions.[/INST] | The reviewers found that the enrollee has Crohn's disease, ulcer and diarrhea which may be reliably diagnosed through wireless capsule endoscopy according to ASGE guidelines. The data shows that capsule endoscopy is useful for diagnosing Crohn's disease and has been proven to be more sensitive than alternatives like CT scans, small bowel follow-through, and enteroclysis. As the requested procedure is likely to provide useful diagnostic information and is more sensitive than conventional ileocolonoscopy, two of the three reviewers determined that it is likely to be more beneficial for the enrollee's evaluation than any available standard therapy. Therefore, the Health Plan's denial should be overturned. The physician reviewers have the necessary qualifications and expertise to evaluate the proposed treatment, and the procedures were not considered experimental or investigational. | The reviewers found that the enrollee has Crohn's disease, ulcer and diarrhea which may be reliably diagnosed through wireless capsule endoscopy according to ASGE guidelines. The data shows that capsule endoscopy is useful for diagnosing Crohn's disease and has been proven to be more sensitive than alternatives like CT scans, small bowel follow-through, and enteroclysis. As the requested procedure is likely to provide useful diagnostic information and is more sensitive than conventional ileocolonoscopy, two of the three reviewers determined that it is likely to be more beneficial for the enrollee's evaluation than any available standard therapy. Therefore, the Health Plan's denial should be overturned. The physician reviewers have the necessary qualifications and expertise to evaluate the proposed treatment, and the procedures were not considered experimental or investigational. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The medical review findings were Internal of Statutory Criteria/Case Summary: An enrollee has requested coverage for the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education. Findings: we found that the submitted documentation supports the medical necessity of the requested services. This patient is likely to benefit from a facility dedicated to neuro-rehabilitation. Per the records, he is displaying symptoms that are behavioral as well as cognitive secondary to anoxic brain injury from carbon monoxide poisoning. Neuro-rehabilitation programs typically have a team-based approach to treating neurobehavioral problems. These teams usually include psychologists, psychiatrists, social workers, occupational therapists and physical therapists. The use of specialized mental health workers is unique to neuro-rehabilitation facilities. This patient requires inpatient level of care as he poses a danger to himself and others. He requires constant supervision. The requested services are medically appropriate in this clinical setting. Therefore, the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. And grounds were Medical Necessity.[/INST] | The treatment is considered medically necessary because my symptoms are behavioral and cognitive secondary to anoxic brain injury from carbon monoxide poisoning, and a neuro-rehabilitation program with a team-based approach, including specialized mental health workers, is unique to neuro-rehabilitation facilities. Irequires constant supervision and inI level of care due to the danger he poses to himself and others. The requested services, including physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management, and family counseling and education, are medically appropriate for the treatment of this condition. | The treatment is considered medically necessary because my symptoms are behavioral and cognitive secondary to anoxic brain injury from carbon monoxide poisoning, and a neuro-rehabilitation program with a team-based approach, including specialized mental health workers, is unique to neuro-rehabilitation facilities. Irequires constant supervision and inI level of care due to the danger he poses to himself and others. The requested services, including physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management, and family counseling and education, are medically appropriate for the treatment of this condition. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. The technique often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks, decrease in biopsies and increase in detection of small cancers. Thus, the addition of breast tomosynthesis was likely of greater benefit to the patient than had her study been done with two-dimensional technique alone. In sum, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two [/INST] | Independent Medical Review: Nature of Statutory Criteria/Case Summary
Patient: [Name], enrollment in [Health Plan] insurance plan.
Medical Condition: Request for breast tomosynthesis for evaluation.
Review Findings: The independent medical review determined that the current medical evidence supports the use of breast tomosynthesis in this clinical setting. Breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks, biopsies, and an increase in detection of small cancers.
Overall, the addition of breast tomosynthesis was likely to provide greater benefit to the I than traditional two-dimensional imaging alone. Consequently, the Health Plan's denial of the requested service should be overturned.
Credentials/Qualifications: The reviewers were all diagnostic radiologists who were actively practicing and certified. They were experts in the treatment of my medical condition and had recent or current clinical experience treating Is with the same or similar medical condition.
Grounds for Revision: The review was experimental and investigational, which was determined to be beyond the scope of review for this Heath Plan. Nevertheless, the review board recommended a second review be completed to address this issue.
In conclusion, this independent medical review determined that the services at issue were likely to be more beneficial to the I than any available standard therapy. Therefore, the Health Plan's denial should be overturned, and another independent medical review should be completed to address any further concerns regarding the experimental and investigational nature of the requested service. | Independent Medical Review: Nature of Statutory Criteria/Case Summary
Patient: [Name], enrollment in [Health Plan] insurance plan.
Medical Condition: Request for breast tomosynthesis for evaluation.
Review Findings: The independent medical review determined that the current medical evidence supports the use of breast tomosynthesis in this clinical setting. Breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks, biopsies, and an increase in detection of small cancers.
Overall, the addition of breast tomosynthesis was likely to provide greater benefit to the I than traditional two-dimensional imaging alone. Consequently, the Health Plan's denial of the requested service should be overturned.
Credentials/Qualifications: The reviewers were all diagnostic radiologists who were actively practicing and certified. They were experts in the treatment of my medical condition and had recent or current clinical experience treating Is with the same or similar medical condition.
Grounds for Revision: The review was experimental and investigational, which was determined to be beyond the scope of review for this Heath Plan. Nevertheless, the review board recommended a second review be completed to address this issue.
In conclusion, this independent medical review determined that the services at issue were likely to be more beneficial to the I than any available standard therapy. Therefore, the Health Plan's denial should be overturned, and another independent medical review should be completed to address any further concerns regarding the experimental and investigational nature of the requested service. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. The technique often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks, decrease in biopsies and increase in detection of small cancers. Thus, the addition of breast tomosynthesis was likely of greater benefit to the patient than had her study been done with two-dimensional technique alone. In sum, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two [/INST] | The experimental/investigational breast tomosynthesis treatment was likely medically necessary to better evaluate the enrollee's medical condition compared to the traditional two-dimensional technique alone. The reviewers found that the technique was more likely to benefit the I with better accuracy and fewer false positives, decreasing the likelihood of biopsies and allowing for earlier detection of small cancers. | The experimental/investigational breast tomosynthesis treatment was likely medically necessary to better evaluate the enrollee's medical condition compared to the traditional two-dimensional technique alone. The reviewers found that the technique was more likely to benefit the I with better accuracy and fewer false positives, decreasing the likelihood of biopsies and allowing for earlier detection of small cancers. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Dear [Patient],
Thank you for your request for authorization and coverage for an electric breast pump. While we understand the importance of breastfeeding and the American College of Obstetricians and Gynecologists endorses and promotes it, informed decisions regarding medical treatment must be made in accordance with our coverage policy.
You have been provided a comprehensive assessment of your medical condition by our internal medical review team. After careful evaluation, our team has determined that an electric breast pump is not medically necessary for your treatment. While electric breast pumps can be effective in certain circumstance, our team has determined that in your medical case, you do not meet the specific criteria for the use of an electric breast pump.
Our team is committed to ensuring that our coverage policy is applied fairly and equitably. As such, we have made a final determination that your request for an electric breast pump is not medically necessary for the treatment of your medical condition.
Thank you for understanding our decision, and we wish you all the best in your breastfeeding journey.
Sincerely,
[Your Name],
Insurance Company
[Company Name][/INST] | Dear Health Plans,
I am writing to appeal the recent denial of my request for an electric breast pump for the treatment of their medical condition.
As per the American College of Obstetricians and Gynecologists (ACOG) guidelines, breastfeeding is encouraged and can be challenging clinical circumstances. In this case, the I has overproduction of breast milk, which could lead to infection and difficulty for the infant latching. For these reasons, the electric breast pump requested by the I is medically necessary to address their medical condition.
I, as an independent medical reviewer, am writing to request that you overturn the denial of the electric breast pump. As an expert in treating conditions similar to my, I am confident that the requested device will provide a safe, effective, and necessary therapy for my medical condition.
I am board certified in obstetrics and gynecology and have extensive recent or current clinical experience treating Is with similar medical conditions. Based on my knowledge and expertise, I find that the electric breast pump requested by the I is medically necessary for the treatment of their medical condition.
I urge you to overturn the denial of the electric breast pump for this I, as it is essential to their overall health and well-being.
Sincerely,
[Your Name] | Dear Health Plans,
I am writing to appeal the recent denial of my request for an electric breast pump for the treatment of their medical condition.
As per the American College of Obstetricians and Gynecologists (ACOG) guidelines, breastfeeding is encouraged and can be challenging clinical circumstances. In this case, the I has overproduction of breast milk, which could lead to infection and difficulty for the infant latching. For these reasons, the electric breast pump requested by the I is medically necessary to address their medical condition.
I, as an independent medical reviewer, am writing to request that you overturn the denial of the electric breast pump. As an expert in treating conditions similar to my, I am confident that the requested device will provide a safe, effective, and necessary therapy for my medical condition.
I am board certified in obstetrics and gynecology and have extensive recent or current clinical experience treating Is with similar medical conditions. Based on my knowledge and expertise, I find that the electric breast pump requested by the I is medically necessary for the treatment of their medical condition.
I urge you to overturn the denial of the electric breast pump for this I, as it is essential to their overall health and well-being.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Dear [Patient],
Thank you for your request for authorization and coverage for an electric breast pump. While we understand the importance of breastfeeding and the American College of Obstetricians and Gynecologists endorses and promotes it, informed decisions regarding medical treatment must be made in accordance with our coverage policy.
You have been provided a comprehensive assessment of your medical condition by our internal medical review team. After careful evaluation, our team has determined that an electric breast pump is not medically necessary for your treatment. While electric breast pumps can be effective in certain circumstance, our team has determined that in your medical case, you do not meet the specific criteria for the use of an electric breast pump.
Our team is committed to ensuring that our coverage policy is applied fairly and equitably. As such, we have made a final determination that your request for an electric breast pump is not medically necessary for the treatment of your medical condition.
Thank you for understanding our decision, and we wish you all the best in your breastfeeding journey.
Sincerely,
[Your Name],
Insurance Company
[Company Name][/INST] | The treatment is considered medically necessary because the I had overproduction of breast milk, which could lead to infection and difficulty for the infant latching. The American College of Obstetricians and Gynecologists (ACOG) recommends breast pumping in such cases as an effective alternative to breastfeeding. The electric breast pump is seen as the most effective method for breast pumping. Therefore, concluded that the requested electric breast pump was necessary for my treatment. | The treatment is considered medically necessary because the I had overproduction of breast milk, which could lead to infection and difficulty for the infant latching. The American College of Obstetricians and Gynecologists (ACOG) recommends breast pumping in such cases as an effective alternative to breastfeeding. The electric breast pump is seen as the most effective method for breast pumping. Therefore, concluded that the requested electric breast pump was necessary for my treatment. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-nave genotype 1 patients should be treated with Harvoni for 12 weeks.These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Credentials/Qualifications: we is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.[/INST] | The treatment is considered medically necessary because the AASLD/IDSA guidelines recommend that all Is with chronic hepatitis C, including those with limited life expectancy, should be treated with Harvoni regardless of fibrosis stage or viral load. The medication is FDA-approved for all genotype 1 Is with chronic hepatitis C and has been shown to reduce the risk of complications and mortality associated with delayed treatment. The physician reviewer, who is an internal medicine physician with sub-specialty certification in gastroenterology and has current or recent clinical experience treating the enrollee's medical condition, determined that the requested treatment with Harvoni for 12 weeks is medically necessary based on the AASLD/IDSA guidelines and recent clinical research. | The treatment is considered medically necessary because the AASLD/IDSA guidelines recommend that all Is with chronic hepatitis C, including those with limited life expectancy, should be treated with Harvoni regardless of fibrosis stage or viral load. The medication is FDA-approved for all genotype 1 Is with chronic hepatitis C and has been shown to reduce the risk of complications and mortality associated with delayed treatment. The physician reviewer, who is an internal medicine physician with sub-specialty certification in gastroenterology and has current or recent clinical experience treating the enrollee's medical condition, determined that the requested treatment with Harvoni for 12 weeks is medically necessary based on the AASLD/IDSA guidelines and recent clinical research. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-nave genotype 1 patients should be treated with Harvoni for 12 weeks.These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Credentials/Qualifications: we is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.[/INST] | Dear Health Plan,
I am writing to appeal the denial of my client's request for Harvoni treatment for hepatitis C virus infection.
As per the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all Is with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. According to these guidelines, regardless of fibrosis stage or viral load, treatment-nave genotype 1 Is should be treated with Harvoni for 12 weeks. This medication is U.S. Food and Drug Administration (FDA)-approved for all Is with chronic hepatitis C genotype 1, regardless of fibrosis stage.
Furthermore, AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Based on this information, the requested treatment with Harvoni for 12 weeks is medically necessary for the treatment of my client's hepatitis C infection.
I understand that the physician reviewer who made the decision may have certain qualifications and credentials. However, I would like to clarify that Iy client in my capacity as their legal representative, and I do not possess the physical or mental qualifications necessary for medical review.
I hope that this appeal is examined thoroughly, and my client's request for Harvoni treatment is approved promptly. If you require any additional information or documentation, please do not hesitate to contact me.
Thank you for your consideration.
Sincerely,
[Your Name] | Dear Health Plan,
I am writing to appeal the denial of my client's request for Harvoni treatment for hepatitis C virus infection.
As per the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all Is with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. According to these guidelines, regardless of fibrosis stage or viral load, treatment-nave genotype 1 Is should be treated with Harvoni for 12 weeks. This medication is U.S. Food and Drug Administration (FDA)-approved for all Is with chronic hepatitis C genotype 1, regardless of fibrosis stage.
Furthermore, AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Based on this information, the requested treatment with Harvoni for 12 weeks is medically necessary for the treatment of my client's hepatitis C infection.
I understand that the physician reviewer who made the decision may have certain qualifications and credentials. However, I would like to clarify that Iy client in my capacity as their legal representative, and I do not possess the physical or mental qualifications necessary for medical review.
I hope that this appeal is examined thoroughly, and my client's request for Harvoni treatment is approved promptly. If you require any additional information or documentation, please do not hesitate to contact me.
Thank you for your consideration.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The requested transcranial magnetic stimulation (TMS) is supported as medically necessary for treatment of the patient's major depressive disorder. However, the requested service was denied by the insurance plan.
The decision was based on an internal review of the patient's medical history and current status, as well as on an internal review of the peer-reviewed medical literature and recent or current actual clinical experience treating patients with major depression.
The reviewer found that TMS is a non-invasive brain stimulating procedure that has been approved by the U.S. Food and Drug Administration (FDA). It tends to be well tolerated with fewer barriers and side effects than electroconvulsive therapy, TMS is likely to prevent the need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression. Most importantly, the American Psychiatric Association (APA) has endorsed use of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.
Therefore, the reviewer determined that the requested service is not medically necessary for treatment of the patient's major depressive disorder. The decision to deny the request was made in error, based on insufficient evidence and inconsistent with current medical practices. The request should stand., and the denial reversed.
The reviewer is board certified in psychiatry and actively practicing, and is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with major depression. The decision to deny the request was based on insufficient evidence and inconsistent with current medical practices. The request should stand., and the denial reversed.[/INST] | The treatment is considered medically necessary because TMS is a well-tolerated and effective non-invasive brain stimulating procedure that has been approved by the FDA, tends to prevent the need for treatment in a more restrictive setting, addresses suboptimal treatment of clinical depression, and is endorsed by the American Psychiatric Association (APA) for acute phase treatment of major depressive disorder. | The treatment is considered medically necessary because TMS is a well-tolerated and effective non-invasive brain stimulating procedure that has been approved by the FDA, tends to prevent the need for treatment in a more restrictive setting, addresses suboptimal treatment of clinical depression, and is endorsed by the American Psychiatric Association (APA) for acute phase treatment of major depressive disorder. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The requested transcranial magnetic stimulation (TMS) is supported as medically necessary for treatment of the patient's major depressive disorder. However, the requested service was denied by the insurance plan.
The decision was based on an internal review of the patient's medical history and current status, as well as on an internal review of the peer-reviewed medical literature and recent or current actual clinical experience treating patients with major depression.
The reviewer found that TMS is a non-invasive brain stimulating procedure that has been approved by the U.S. Food and Drug Administration (FDA). It tends to be well tolerated with fewer barriers and side effects than electroconvulsive therapy, TMS is likely to prevent the need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression. Most importantly, the American Psychiatric Association (APA) has endorsed use of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.
Therefore, the reviewer determined that the requested service is not medically necessary for treatment of the patient's major depressive disorder. The decision to deny the request was made in error, based on insufficient evidence and inconsistent with current medical practices. The request should stand., and the denial reversed.
The reviewer is board certified in psychiatry and actively practicing, and is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with major depression. The decision to deny the request was based on insufficient evidence and inconsistent with current medical practices. The request should stand., and the denial reversed.[/INST] | Appeal Letter:
Dear Health Plan [Name],
I am writing to appeal the recent denial for Transcranial Magnetic Stimulation (TMS) treatment for my major depressive disorder.
After thorough review of the nature of statutory criteria/case summary, I believe the requested TMS is supported as medically necessary for treating my major depressive disorder. The physician reviewer has found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of Is with major depressive disorder, and has been approved by the U.S. Food and Drug Administration. Furthermore, TMS tends to be well-tolerated with fewer barriers and side effects than electroconvulsive therapy and is likely to prevent the need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression.
As per the American Psychiatric Association, TMS has been endorsed as a treatment for the acute phase of major depressive disorder after failure of at least one antidepressant trial.
As a [Patient], I am suffering from a serious medical condition and have exhausted all reasonable alternative treatments. I strongly believe that TMS will provide me with an effective and appropriate treatment option for my major depressive disorder.
I am particularly disappointed in the health plan's denial of this treatment, as it contradicts the medical consensus and the findings of the physician reviewer. I urge you to reconsider the denial and provide me with the requested treatment as soon as possible.
Thank you for your consideration.
Sincerely,
[Patient Name] | Appeal Letter:
Dear Health Plan [Name],
I am writing to appeal the recent denial for Transcranial Magnetic Stimulation (TMS) treatment for my major depressive disorder.
After thorough review of the nature of statutory criteria/case summary, I believe the requested TMS is supported as medically necessary for treating my major depressive disorder. The physician reviewer has found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of Is with major depressive disorder, and has been approved by the U.S. Food and Drug Administration. Furthermore, TMS tends to be well-tolerated with fewer barriers and side effects than electroconvulsive therapy and is likely to prevent the need for treatment in a more restrictive setting to address suboptimal treatment of clinical depression.
As per the American Psychiatric Association, TMS has been endorsed as a treatment for the acute phase of major depressive disorder after failure of at least one antidepressant trial.
As a [Patient], I am suffering from a serious medical condition and have exhausted all reasonable alternative treatments. I strongly believe that TMS will provide me with an effective and appropriate treatment option for my major depressive disorder.
I am particularly disappointed in the health plan's denial of this treatment, as it contradicts the medical consensus and the findings of the physician reviewer. I urge you to reconsider the denial and provide me with the requested treatment as soon as possible.
Thank you for your consideration.
Sincerely,
[Patient Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Internal medical review findings regarding the patient's request for Xiaflex to treat his Peyronie's disease were conducted by a urologist who is board certified and actively practicing. The reviewer determined that the submitted documentation supports the medical necessity of the requested medication, as the patient is unlikely to experience resolution of his penile curvature without treatment and has failed alternative treatments. The current medical evidence supports the use of Xiaflex in this particular clinical setting, and there are no viable alternatives to a surgical procedure with an uncertain outcome. The enrollees condition has a significant impact on his well-being and quality of life, and Xiaflex is considered the standard of care for the treatment of this patient. Based on these findings, the reviewer determined that Xiaflex is medically indicated for the enrollees treatment. Therefore, the health plan's denial of the medication should stand.[/INST] | Dear [Health Plan],
I am writing to appeal the denial of Xiaflex for my treatment of Peyronies disease. I believe the denial is not based on sound medical judgment and I request the reconsideration of my case.
I have been diagnosed with Peyronies disease and have been treated with other methods, but none of them have provided a satisfactory resolution to my condition. I have exhausted other viable alternatives to treatment and the only viable option remaining is a surgical procedure with uncertain outcomes. The cognitive psychoneuroendocrine consequences of Peyronies disease can be severe and have a significant impact on well-being and quality of life.
The independent medical review found that the requested medication, Xiaflex, is a standard of care for this clinical setting. The reviewer noted that the submitted documentation supports the medical necessity of the requested medication and that the I is unlikely to experience resolution without treatment. The current medical evidence supports the request and the scheme used by the physician should be confirmed.
I strongly believe that Xiaflex is medically necessary for treatment of my condition, and I urge you to overturn the denial and approve my request for treatment.
Thank you for your consideration.
Sincerely,
[Your Name] | Dear [Health Plan],
I am writing to appeal the denial of Xiaflex for my treatment of Peyronies disease. I believe the denial is not based on sound medical judgment and I request the reconsideration of my case.
I have been diagnosed with Peyronies disease and have been treated with other methods, but none of them have provided a satisfactory resolution to my condition. I have exhausted other viable alternatives to treatment and the only viable option remaining is a surgical procedure with uncertain outcomes. The cognitive psychoneuroendocrine consequences of Peyronies disease can be severe and have a significant impact on well-being and quality of life.
The independent medical review found that the requested medication, Xiaflex, is a standard of care for this clinical setting. The reviewer noted that the submitted documentation supports the medical necessity of the requested medication and that the I is unlikely to experience resolution without treatment. The current medical evidence supports the request and the scheme used by the physician should be confirmed.
I strongly believe that Xiaflex is medically necessary for treatment of my condition, and I urge you to overturn the denial and approve my request for treatment.
Thank you for your consideration.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Internal medical review findings regarding the patient's request for Xiaflex to treat his Peyronie's disease were conducted by a urologist who is board certified and actively practicing. The reviewer determined that the submitted documentation supports the medical necessity of the requested medication, as the patient is unlikely to experience resolution of his penile curvature without treatment and has failed alternative treatments. The current medical evidence supports the use of Xiaflex in this particular clinical setting, and there are no viable alternatives to a surgical procedure with an uncertain outcome. The enrollees condition has a significant impact on his well-being and quality of life, and Xiaflex is considered the standard of care for the treatment of this patient. Based on these findings, the reviewer determined that Xiaflex is medically indicated for the enrollees treatment. Therefore, the health plan's denial of the medication should stand.[/INST] | The treatment is considered medically necessary because the I has failed other treatments and the physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The current medical evidence supports the requested medication in this clinical setting and there is a lack of viable alternatives except a surgical procedure with uncertain outcome. The condition causes significant impact on well-being and quality of life, and Xiaflex is standard of care for the treatment of this I. The reviewer determined that the requested medication is medically necessary for treatment of my medical condition. | The treatment is considered medically necessary because the I has failed other treatments and the physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The current medical evidence supports the requested medication in this clinical setting and there is a lack of viable alternatives except a surgical procedure with uncertain outcome. The condition causes significant impact on well-being and quality of life, and Xiaflex is standard of care for the treatment of this I. The reviewer determined that the requested medication is medically necessary for treatment of my medical condition. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Dear [Patient],
Thank you for your recent request for coverage for percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine. We appreciate the care team's thorough review of your case and provide the following response.
After careful consideration of the nature of statutory criteria, case summary, and all relevant clinical information, our reviewers have determined that the requested services are not medically necessary. While the independent medical review findings indicate that DRG stimulation may be effective for treating various types of neuropathic pain, our reviewers have found no specific evidence that supports the use of DRG stimulation for your specific medical condition.
Furthermore, we have noted that you have already obtained psychological clearance for a spinal cord stimulator and have undergone a trial of DRG stimulation with documented pain relief. Therefore, we do not see the need to continue with the proposed DRG stimulation treatment.
We apologize for any inconvenience this decision may cause, and we encourage you to discuss your treatment options with your care team. If you have any further questions or concerns, please do not hesitate to contact us.
Sincerely,
[Your Health Plan's Name][/INST] | The independent medical review found that percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine is medically necessary for the treatment of chronic focal neuropathic pain consistent with my left lower extremity causalgia. The review concluded that there is adequate randomized clinical trial evidence that DRG placement provides superior pain relief to spinal cord stimulation for complex regional pain syndrome (CRPS) and causalgia of the lower limb. Ipresents with a history of refractory chronic low back and left leg pain and has been diagnosed with left lower extremity causalgia. Clinical examination findings have documented no focal neurologic deficits, and there is no imaging or electrodiagnostic evidence of nerve root compression. Ihas obtained psychological clearance for the use of a spinal cord stimulator and underwent a trial of DRG stimulation with documented 100% pain relief, improvement in ability to perform activities of daily living, and reduction in medication use. The current evidence-based medical literature supports the use of DRG stimulation for the treatment of chronic focal neuropathic pain consistent with my medical condition. | The independent medical review found that percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine is medically necessary for the treatment of chronic focal neuropathic pain consistent with my left lower extremity causalgia. The review concluded that there is adequate randomized clinical trial evidence that DRG placement provides superior pain relief to spinal cord stimulation for complex regional pain syndrome (CRPS) and causalgia of the lower limb. Ipresents with a history of refractory chronic low back and left leg pain and has been diagnosed with left lower extremity causalgia. Clinical examination findings have documented no focal neurologic deficits, and there is no imaging or electrodiagnostic evidence of nerve root compression. Ihas obtained psychological clearance for the use of a spinal cord stimulator and underwent a trial of DRG stimulation with documented 100% pain relief, improvement in ability to perform activities of daily living, and reduction in medication use. The current evidence-based medical literature supports the use of DRG stimulation for the treatment of chronic focal neuropathic pain consistent with my medical condition. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Dear [Patient],
Thank you for your recent request for coverage for percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine. We appreciate the care team's thorough review of your case and provide the following response.
After careful consideration of the nature of statutory criteria, case summary, and all relevant clinical information, our reviewers have determined that the requested services are not medically necessary. While the independent medical review findings indicate that DRG stimulation may be effective for treating various types of neuropathic pain, our reviewers have found no specific evidence that supports the use of DRG stimulation for your specific medical condition.
Furthermore, we have noted that you have already obtained psychological clearance for a spinal cord stimulator and have undergone a trial of DRG stimulation with documented pain relief. Therefore, we do not see the need to continue with the proposed DRG stimulation treatment.
We apologize for any inconvenience this decision may cause, and we encourage you to discuss your treatment options with your care team. If you have any further questions or concerns, please do not hesitate to contact us.
Sincerely,
[Your Health Plan's Name][/INST] | Dear [Health Plan],
I am appealing your recent denial of the requested authorization and coverage for percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine. As a I, I have been diagnosed with left lower extremity causalgia and have been looking into effective treatment options.
After thorough research and consultation with medical professionals, I have come to the conclusion that DRG stimulation is medically necessary for the treatment of my, and others with similar, medical condition.
DRG stimulation has been shown in randomized clinical trials to provide superior pain relief to spinal cord stimulation for complex regional pain syndrome (CRPS) and causalgia of the lower limb. It has also been shown to be effective for a variety of neuropathic pain syndromes, in addition to CRPS. Other studies have concluded that DRG might be an effective long-term method of treating discrete, localized areas of chronic neuropathic pain.
I have obtained psychological clearance for the use of a spinal cord stimulator, and I underwent a trial of DRG stimulation with documented 100% pain relief, improvement in my ability to perform activities of daily living, and reduction in medication use. Current evidence-based medical literature supports the use of DRG stimulation for the treatment of chronic focal neuropathic pain consistent with my left lower extremity causalgia.
Iyself, not as an individual representing a doctor’s office. I am writing this appeal as a I who is seeking appropriate and effective treatment for my medical condition, and I believe that DRG stimulation is an effective and necessary treatment option for me.
I urge you to reverse your denial of the requested services and to provide me with the necessary authorization and coverage for percutaneous implantation of a DRG stimulator into the lumbar spine.
Thank you for your consideration.
Sincerely,
[Your name] | Dear [Health Plan],
I am appealing your recent denial of the requested authorization and coverage for percutaneous implantation of a dorsal root ganglion (DRG) stimulator into the lumbar spine. As a I, I have been diagnosed with left lower extremity causalgia and have been looking into effective treatment options.
After thorough research and consultation with medical professionals, I have come to the conclusion that DRG stimulation is medically necessary for the treatment of my, and others with similar, medical condition.
DRG stimulation has been shown in randomized clinical trials to provide superior pain relief to spinal cord stimulation for complex regional pain syndrome (CRPS) and causalgia of the lower limb. It has also been shown to be effective for a variety of neuropathic pain syndromes, in addition to CRPS. Other studies have concluded that DRG might be an effective long-term method of treating discrete, localized areas of chronic neuropathic pain.
I have obtained psychological clearance for the use of a spinal cord stimulator, and I underwent a trial of DRG stimulation with documented 100% pain relief, improvement in my ability to perform activities of daily living, and reduction in medication use. Current evidence-based medical literature supports the use of DRG stimulation for the treatment of chronic focal neuropathic pain consistent with my left lower extremity causalgia.
Iyself, not as an individual representing a doctor’s office. I am writing this appeal as a I who is seeking appropriate and effective treatment for my medical condition, and I believe that DRG stimulation is an effective and necessary treatment option for me.
I urge you to reverse your denial of the requested services and to provide me with the necessary authorization and coverage for percutaneous implantation of a DRG stimulator into the lumbar spine.
Thank you for your consideration.
Sincerely,
[Your name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iontophoresis. This patient presents with palmar, plantar, and axillary hyperhidrosis that has only partially improved with Drysol, oxybutynin, and topical antiperspirants. The provider recommended treatment with iontophoresis. There are data from clinical trials reporting that iontophoresis can be successful in alleviating the symptoms of palmar or plantar hyperhidrosis in approximately 85% of patients treated. Iontophoresis is specifically indicated for the palms and soles of the feet, but there is a lack of data demonstrating similar efficacy in the axillae. Currently, iontophoresis is considered a first-line therapy for this patients palmar and plantar hyperhidrosis over the remaining alternative, Botox, given the pain associated with Botox injections at these sites. In summary, iontophoresis to the palms and feet soles is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: All three physician reviewers found a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Specifically, all three medical experts decided that iontophoresis to the palms and feet soles is likely to be more beneficial for you than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. and grounds were Experimental/Investigational.[/INST] | Dear Health Plan,
I am writing to request that you review my recent medical review findings related to my request for authorization and coverage for iontophoresis for my hyperhidrosis condition.
As you may know, I have been experiencing palmar, plantar, and axillary hyperhidrosis that has not been significantly improved with Drysol, oxybutynin, or topical antiperspirants. My provider has recommended treatment with iontophoresis. According to a review of clinical studies, iontophoresis has been shown to be effective in reducing the symptoms of palmar or plantar hyperhidrosis in approximately 85% of Is treated.
However, there are limited data available on the effectiveness of iontophoresis in addressing axillary hyperhidrosis, which means that iontophoresis in this area may not be as beneficial as standard therapies.
Despite this, the experimental/investigational nature of iontophoresis for axillary hyperhidrosis does not diminish its potential effectiveness in resolving my medical condition to a greater extent than any standard therapy currently available.
Thank you for your consideration of my request for authorization and coverage for iontophoresis. I appreciate your prompt attention to this matter and look forward to hearing from you soon.
Sincerely,
[Your Name] | Dear Health Plan,
I am writing to request that you review my recent medical review findings related to my request for authorization and coverage for iontophoresis for my hyperhidrosis condition.
As you may know, I have been experiencing palmar, plantar, and axillary hyperhidrosis that has not been significantly improved with Drysol, oxybutynin, or topical antiperspirants. My provider has recommended treatment with iontophoresis. According to a review of clinical studies, iontophoresis has been shown to be effective in reducing the symptoms of palmar or plantar hyperhidrosis in approximately 85% of Is treated.
However, there are limited data available on the effectiveness of iontophoresis in addressing axillary hyperhidrosis, which means that iontophoresis in this area may not be as beneficial as standard therapies.
Despite this, the experimental/investigational nature of iontophoresis for axillary hyperhidrosis does not diminish its potential effectiveness in resolving my medical condition to a greater extent than any standard therapy currently available.
Thank you for your consideration of my request for authorization and coverage for iontophoresis. I appreciate your prompt attention to this matter and look forward to hearing from you soon.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings were Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iontophoresis. This patient presents with palmar, plantar, and axillary hyperhidrosis that has only partially improved with Drysol, oxybutynin, and topical antiperspirants. The provider recommended treatment with iontophoresis. There are data from clinical trials reporting that iontophoresis can be successful in alleviating the symptoms of palmar or plantar hyperhidrosis in approximately 85% of patients treated. Iontophoresis is specifically indicated for the palms and soles of the feet, but there is a lack of data demonstrating similar efficacy in the axillae. Currently, iontophoresis is considered a first-line therapy for this patients palmar and plantar hyperhidrosis over the remaining alternative, Botox, given the pain associated with Botox injections at these sites. In summary, iontophoresis to the palms and feet soles is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: All three physician reviewers found a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Specifically, all three medical experts decided that iontophoresis to the palms and feet soles is likely to be more beneficial for you than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. and grounds were Experimental/Investigational.[/INST] | Iontophoresis to the palms and feet soles is likely to be more beneficial for treatment of my medical condition than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of my medical condition than any available standard therapy. This was determined by three physician reviewers who are board certified in dermatology and have expertise in the treatment of the enrollees medical condition. The treatment is considered medically necessary because there are data from clinical trials reporting that iontophoresis can be successful in alleviating the symptoms of palmar or plantar hyperhidrosis in approximately 85% of Is treated. Iontophoresis is specifically indicated for the palms and soles of the feet, and currently, iontophoresis is considered a first-line therapy for my palmar and plantar hyperhidrosis over the remaining alternative, Botox, given the pain associated with Botox injections at these sites. | Iontophoresis to the palms and feet soles is likely to be more beneficial for treatment of my medical condition than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of my medical condition than any available standard therapy. This was determined by three physician reviewers who are board certified in dermatology and have expertise in the treatment of the enrollees medical condition. The treatment is considered medically necessary because there are data from clinical trials reporting that iontophoresis can be successful in alleviating the symptoms of palmar or plantar hyperhidrosis in approximately 85% of Is treated. Iontophoresis is specifically indicated for the palms and soles of the feet, and currently, iontophoresis is considered a first-line therapy for my palmar and plantar hyperhidrosis over the remaining alternative, Botox, given the pain associated with Botox injections at these sites. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The requested independent medical review findings for the enrollee's coverage of narrowband ultraviolet-B (NVB) radiation three times per week for treatment of severe psoriasis with associated symptoms have been reviewed by an internal reviewer who is board certified in dermatology and has current clinical experience treating those with similar conditions. The reviewer has concluded that NVB is an effective and reasonable treatment option for this patient's chronic condition and that treatment three times per week for several months is necessary for achieving clearance of psoriasis symptoms. Given the reviewer's expertise and the effectiveness of NVB treatment for psoriasis, the denial of coverage for this treatment based on medical necessity grounds should stand.[/INST] | The treatment with NVB radiation three times per week is considered medically necessary as it is an effective treatment option for severe psoriasis, a chronic skin disease, which causes significant flaking of the skin, pruritus, and social distress. The NPF reports that this treatment results in an average clearance of 58 days. Ihas had excellent results with this treatment in the past. The independent medical reviewer, who is board certified in dermatology and has recent or current actual clinical experience treating those with this medical condition, supported the NPF's recommendation for this treatment. | The treatment with NVB radiation three times per week is considered medically necessary as it is an effective treatment option for severe psoriasis, a chronic skin disease, which causes significant flaking of the skin, pruritus, and social distress. The NPF reports that this treatment results in an average clearance of 58 days. Ihas had excellent results with this treatment in the past. The independent medical reviewer, who is board certified in dermatology and has recent or current actual clinical experience treating those with this medical condition, supported the NPF's recommendation for this treatment. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The requested independent medical review findings for the enrollee's coverage of narrowband ultraviolet-B (NVB) radiation three times per week for treatment of severe psoriasis with associated symptoms have been reviewed by an internal reviewer who is board certified in dermatology and has current clinical experience treating those with similar conditions. The reviewer has concluded that NVB is an effective and reasonable treatment option for this patient's chronic condition and that treatment three times per week for several months is necessary for achieving clearance of psoriasis symptoms. Given the reviewer's expertise and the effectiveness of NVB treatment for psoriasis, the denial of coverage for this treatment based on medical necessity grounds should stand.[/INST] | The appeal with the independent medical review findings regarding my request for authorization and coverage for narrowband ultraviolet-B (NVB) radiation three times per week is on behalf of the I, not that of a doctor's office. Ihas a diagnosis of severe psoriasis with the associated symptoms, and treatment with NVB radiation has been effective in the past for the I with few side effects. According to the National Psoriasis Foundation (NPF), phototherapy is a reasonable and effective treatment option for Is requiring more than topical medications, those who need to avoid systemic medications, or those seeking an adjunct to a failing treatment regimen. NPF reports that three times per week treatment with NVB radiation resulted in an average clearance of 58 days for Is.
Given the evidence of my medical history, current situation, and previous success with NVB radiation treatment, the requested three times per week NVB radiation is medically necessary for my treatment of psoriasis. My request for authorization and coverage for NVB radiation should be approved, and the Health Plan's denial should be overturned. | The appeal with the independent medical review findings regarding my request for authorization and coverage for narrowband ultraviolet-B (NVB) radiation three times per week is on behalf of the I, not that of a doctor's office. Ihas a diagnosis of severe psoriasis with the associated symptoms, and treatment with NVB radiation has been effective in the past for the I with few side effects. According to the National Psoriasis Foundation (NPF), phototherapy is a reasonable and effective treatment option for Is requiring more than topical medications, those who need to avoid systemic medications, or those seeking an adjunct to a failing treatment regimen. NPF reports that three times per week treatment with NVB radiation resulted in an average clearance of 58 days for Is.
Given the evidence of my medical history, current situation, and previous success with NVB radiation treatment, the requested three times per week NVB radiation is medically necessary for my treatment of psoriasis. My request for authorization and coverage for NVB radiation should be approved, and the Health Plan's denial should be overturned. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings concluded that the patient's complex illness burden of borderline personality disorder, including but not limited to symptoms such as ego fragmentation, clinical depression, auditory hallucinations, dissociation, recurrent suicidality, limited coping skills and self-defeating coping strategies, increases their risk for a poor clinical outcome if not treated appropriately. Dialectical behavior therapy (DBT) is deemed medically necessary for this patient based on an abundance of evidence demonstrating functional impairment and poor coping skills. DBT is a well-established evidence-based intervention that has been trusted and recommended by healthcare professionals. Additionally, the therapy's potential for improving the patient's condition and thwarting a more severe episode of illness signals its appropriateness and value as a treatment option. Therefore, DBT appears to meet the requisite criteria for medical necessity.
Respectfully requesting that the Health Plan review the request for dialectical behavior therapy (DBT) for treatment of the patient's behavioral health condition and overturn its denial based on the above findings.
Credentials and Qualifications: The reviewer is board certified in psychiatry and practices actively. The reviewer is an expert in treating the patient's medical condition and possesses extensive knowledge about the proposed treatment through recent or current clinical experience. The review was conducted under the grounds of medical necessity.[/INST] | The request for dialectical behavior therapy (DBT) was determined medically necessary by an independent medical reviewer due to the enrollee's complex illness burden consisting of multiple symptoms such as borderline personality disorder, ego fragmentation, clinical depression, auditory hallucinations, dissociation, recurrent suicidality, and limited coping skills and self-defeating strategies. The therapist's recommendation for DBT was also taken into consideration as a useful and evidence-based intervention for this type of condition. Additionally, DBT is expected to result in an improvement in my condition and prevent a future, more serious episode of illness. | The request for dialectical behavior therapy (DBT) was determined medically necessary by an independent medical reviewer due to the enrollee's complex illness burden consisting of multiple symptoms such as borderline personality disorder, ego fragmentation, clinical depression, auditory hallucinations, dissociation, recurrent suicidality, and limited coping skills and self-defeating strategies. The therapist's recommendation for DBT was also taken into consideration as a useful and evidence-based intervention for this type of condition. Additionally, DBT is expected to result in an improvement in my condition and prevent a future, more serious episode of illness. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
The internal medical review findings concluded that the patient's complex illness burden of borderline personality disorder, including but not limited to symptoms such as ego fragmentation, clinical depression, auditory hallucinations, dissociation, recurrent suicidality, limited coping skills and self-defeating coping strategies, increases their risk for a poor clinical outcome if not treated appropriately. Dialectical behavior therapy (DBT) is deemed medically necessary for this patient based on an abundance of evidence demonstrating functional impairment and poor coping skills. DBT is a well-established evidence-based intervention that has been trusted and recommended by healthcare professionals. Additionally, the therapy's potential for improving the patient's condition and thwarting a more severe episode of illness signals its appropriateness and value as a treatment option. Therefore, DBT appears to meet the requisite criteria for medical necessity.
Respectfully requesting that the Health Plan review the request for dialectical behavior therapy (DBT) for treatment of the patient's behavioral health condition and overturn its denial based on the above findings.
Credentials and Qualifications: The reviewer is board certified in psychiatry and practices actively. The reviewer is an expert in treating the patient's medical condition and possesses extensive knowledge about the proposed treatment through recent or current clinical experience. The review was conducted under the grounds of medical necessity.[/INST] | Dear [Health Plan],
I am writing on behalf of [I name] to appeal your recent denial of dialectical behavior therapy (DBT) for their behavioral health condition. As per your medical review, which I have attached, the physician reviewer found that DBT is medically necessary for this particular case, as my complex illness burden and clinically significant symptoms of borderline personality disorder place them at high risk for a poor clinical outcome without appropriate treatment.
As per the medical review, the physician reviewer found that DBT is evidence-based and has been shown to benefit those with borderline personality disorder, particularly in improving their ability to manage their emotions, develop a greater sense of self-acceptance, and foster interpersonal effectiveness. Furthermore, the physician reviewer noted that DBT has been recommended by clinicians familiar with the case as a reasonable and expected intervention for this I.
While I do not have any credentials other than my status as an advocate for this I, I want to emphasize that this I requires urgent and ongoing mental health support to help manage their complex illness. DBT offers a structured, evidence-based approach to addressing the individual challenges and symptoms of borderline personality disorder, and I strongly believe that it is the best course of treatment for this I.
I urge you to reconsider your denial of DBT and grant coverage for this I, as it is both medically necessary and in the best interest of their overall health and well-being.
Sincerely,
[Your Name] | Dear [Health Plan],
I am writing on behalf of [I name] to appeal your recent denial of dialectical behavior therapy (DBT) for their behavioral health condition. As per your medical review, which I have attached, the physician reviewer found that DBT is medically necessary for this particular case, as my complex illness burden and clinically significant symptoms of borderline personality disorder place them at high risk for a poor clinical outcome without appropriate treatment.
As per the medical review, the physician reviewer found that DBT is evidence-based and has been shown to benefit those with borderline personality disorder, particularly in improving their ability to manage their emotions, develop a greater sense of self-acceptance, and foster interpersonal effectiveness. Furthermore, the physician reviewer noted that DBT has been recommended by clinicians familiar with the case as a reasonable and expected intervention for this I.
While I do not have any credentials other than my status as an advocate for this I, I want to emphasize that this I requires urgent and ongoing mental health support to help manage their complex illness. DBT offers a structured, evidence-based approach to addressing the individual challenges and symptoms of borderline personality disorder, and I strongly believe that it is the best course of treatment for this I.
I urge you to reconsider your denial of DBT and grant coverage for this I, as it is both medically necessary and in the best interest of their overall health and well-being.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
There will be a review of the following request: The enrollee has requested authorization and coverage for Cologuard screening for evaluation of the enrollee's risk of colon cancer.
The medical necessity for this request was assessed by an internal reviewer who found that, in accordance with U.S. Food and Drug Administration (FDA) approval and American Cancer Society guidelines, Cologuard is recommended for evaluation of the patient's medical condition. The reviewer also noted that while colonoscopy has the highest recommendation from the U.S. Preventive Services Task Force, the patient has provided a valid relative contraindication to colonoscopy due to significant adverse symptoms and distress with bowel preparation.
Based on these grounds, the reviewer determined that the requested service is not medically necessary for evaluation of the patient's medical condition. The investigation of this request will proceed based on the final result.[/INST] | Based on the review finding of medical necessity, the following appeal letter has been written to the Health Plan:
Dear Health Plan:
I am writing to request an appeal for the recent authorization and coverage denial for Cologuard screening for evaluation of colorectal cancer risk in our enrollee. Our I has requested this service in accordance with their medical condition and the applicable statutory criteria.
As per the review findings, the physician believes that requesting Cologuard screening is medically necessary for the evaluation of our I's condition. The test has been U.S. Food and Drug Administration (FDA)-approved for use in average-risk Is and has proven 92% sensitive for detecting colon cancer. Furthermore, Cologuard has been recommended by the American Cancer Society guidelines for colorectal cancer screening.
Our I has provided a valid relative contraindication to colonoscopy, as they will not be able to undergo bowel preparation without significant adverse symptoms and distress. Colonoscopy, although recommended by the U.S. Preventive Services Task Force, does not appear to be an appropriate or safe option for this I.
Considering these reasons, we request that the denial of Cologuard screening be overturned. The reviewer determined that the requested service is medically necessary for the evaluation of my medical condition, and we believe that this decision is in the best interest of our I's health.
Thank you for your consideration.
Sincerely,
[Your Name] | Based on the review finding of medical necessity, the following appeal letter has been written to the Health Plan:
Dear Health Plan:
I am writing to request an appeal for the recent authorization and coverage denial for Cologuard screening for evaluation of colorectal cancer risk in our enrollee. Our I has requested this service in accordance with their medical condition and the applicable statutory criteria.
As per the review findings, the physician believes that requesting Cologuard screening is medically necessary for the evaluation of our I's condition. The test has been U.S. Food and Drug Administration (FDA)-approved for use in average-risk Is and has proven 92% sensitive for detecting colon cancer. Furthermore, Cologuard has been recommended by the American Cancer Society guidelines for colorectal cancer screening.
Our I has provided a valid relative contraindication to colonoscopy, as they will not be able to undergo bowel preparation without significant adverse symptoms and distress. Colonoscopy, although recommended by the U.S. Preventive Services Task Force, does not appear to be an appropriate or safe option for this I.
Considering these reasons, we request that the denial of Cologuard screening be overturned. The reviewer determined that the requested service is medically necessary for the evaluation of my medical condition, and we believe that this decision is in the best interest of our I's health.
Thank you for your consideration.
Sincerely,
[Your Name] |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
There will be a review of the following request: The enrollee has requested authorization and coverage for Cologuard screening for evaluation of the enrollee's risk of colon cancer.
The medical necessity for this request was assessed by an internal reviewer who found that, in accordance with U.S. Food and Drug Administration (FDA) approval and American Cancer Society guidelines, Cologuard is recommended for evaluation of the patient's medical condition. The reviewer also noted that while colonoscopy has the highest recommendation from the U.S. Preventive Services Task Force, the patient has provided a valid relative contraindication to colonoscopy due to significant adverse symptoms and distress with bowel preparation.
Based on these grounds, the reviewer determined that the requested service is not medically necessary for evaluation of the patient's medical condition. The investigation of this request will proceed based on the final result.[/INST] | The treatment is considered medically necessary because it was recommended by the American Cancer Society guidelines, and the I provided a valid relative contraindication to colonoscopy. The test Cologuard was found to be 92% sensitive for detection of colon cancer and can detect most adenomas if they have high-grade dysplasia. | The treatment is considered medically necessary because it was recommended by the American Cancer Society guidelines, and the I provided a valid relative contraindication to colonoscopy. The test Cologuard was found to be 92% sensitive for detection of colon cancer and can detect most adenomas if they have high-grade dysplasia. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Based on our review of the case, our insurance policy does not cover the requested CPT codes 15832, 15835, 15836, 15839, and 19316 for the patient's requested excision of excessive skin and subcutaneous tissue, along with mastpexy. After reviewing the clinical documentation and images, we have determined that the requested procedures are cosmetic in nature and do not meet the criteria for medical necessity under our policy.
Our policy covers medically necessary surgical procedures performed to treat functional abnormalities, but not procedures solely performed to enhance a patient's appearance. Based on our review, the requested procedures, including the mastpexy, are being performed solely to improve a patient's appearance.
In addition, our policy does not cover the treatment of obesity as a disease. While the patient may have excess skin as a result of her obesity, this is not directly related to obesity itself, and cannot be considered a functional abnormality.
Therefore, we are unable to approve the requested procedures for reimbursement. We suggest that the patient consult with a physician who can determine whether the requested procedures are truly medically necessary and will improve functional abnormalities, and who can discuss alternative treatment options that may be covered under their insurance policy.
Grounds for denial: Not Medical Necessity[/INST] | On behalf of the user, I am writing an appeal for medical necessity for excision, excessive skin and subcutaneous tissue of the breasts and other areas following massive weight loss. Ihas requested the procedure on her thighs (CPT 15832), buttock (15835), arms (15836), and other areas (15839) for treatment of excess skin. Based on the photographs and clinical documentation provided, the physician reviewer found that the overlap of the breasts is an abnormal enlargement that worsens with correction of the underlying disease. The requested procedure of the breasts (19316) is being performed to improve function, and will create a normal appearance to the extent possible. Iis documented by more than one provider to have functional problems as a result of the overlapping skin in this area.
Despite specific functional problems solely related to this area not being detailed, the photos of the breasts show that she is likely to have problems with the overlap. It's also noted that the records describe the presence of functional problems including rashes, dermatitis, malodor, and discomfort with physical activity. As the American Society of Plastic Surgeons states, surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a I's appearance in the absence of any signs or symptoms of functional abnormalities, it's not considered compensable. However, in this case, the documentation provided indicates that surgery to remove the excessive skin is being performed to improve functional problems for the breasts, and therefore should be considered reconstructive in nature and approved.
The photos of the thighs, buttock, arms, and other areas show milder abnormalities than the breasts, and in the absence of greater detail of functional problems related to the other anatomic areas, additional procedures may be considered cosmetic. However, these mild abnormalities would still require additional documentation specifically detailing their genetic functional problems to determine if they should also be considered medically necessary.
In summary, there are indications for medically necessary surgery for treatment of skin overlap following massive weight loss. The requested procedure for the breasts (19316) is reconstructive in nature and should be approved as medically necessary. Additional procedures may be considered cosmetic, but would require detailed documentation of their specific genetic functional problems to determine if they should also be considered medically necessary. | On behalf of the user, I am writing an appeal for medical necessity for excision, excessive skin and subcutaneous tissue of the breasts and other areas following massive weight loss. Ihas requested the procedure on her thighs (CPT 15832), buttock (15835), arms (15836), and other areas (15839) for treatment of excess skin. Based on the photographs and clinical documentation provided, the physician reviewer found that the overlap of the breasts is an abnormal enlargement that worsens with correction of the underlying disease. The requested procedure of the breasts (19316) is being performed to improve function, and will create a normal appearance to the extent possible. Iis documented by more than one provider to have functional problems as a result of the overlapping skin in this area.
Despite specific functional problems solely related to this area not being detailed, the photos of the breasts show that she is likely to have problems with the overlap. It's also noted that the records describe the presence of functional problems including rashes, dermatitis, malodor, and discomfort with physical activity. As the American Society of Plastic Surgeons states, surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a I's appearance in the absence of any signs or symptoms of functional abnormalities, it's not considered compensable. However, in this case, the documentation provided indicates that surgery to remove the excessive skin is being performed to improve functional problems for the breasts, and therefore should be considered reconstructive in nature and approved.
The photos of the thighs, buttock, arms, and other areas show milder abnormalities than the breasts, and in the absence of greater detail of functional problems related to the other anatomic areas, additional procedures may be considered cosmetic. However, these mild abnormalities would still require additional documentation specifically detailing their genetic functional problems to determine if they should also be considered medically necessary.
In summary, there are indications for medically necessary surgery for treatment of skin overlap following massive weight loss. The requested procedure for the breasts (19316) is reconstructive in nature and should be approved as medically necessary. Additional procedures may be considered cosmetic, but would require detailed documentation of their specific genetic functional problems to determine if they should also be considered medically necessary. |
[INST] <<SYS>>You possess extensive medical expertise and enjoy crafting appeals for health insurance denials as a personal interest.<</SYS>>Write a health insurance appeal given the provided context.
Based on our review of the case, our insurance policy does not cover the requested CPT codes 15832, 15835, 15836, 15839, and 19316 for the patient's requested excision of excessive skin and subcutaneous tissue, along with mastpexy. After reviewing the clinical documentation and images, we have determined that the requested procedures are cosmetic in nature and do not meet the criteria for medical necessity under our policy.
Our policy covers medically necessary surgical procedures performed to treat functional abnormalities, but not procedures solely performed to enhance a patient's appearance. Based on our review, the requested procedures, including the mastpexy, are being performed solely to improve a patient's appearance.
In addition, our policy does not cover the treatment of obesity as a disease. While the patient may have excess skin as a result of her obesity, this is not directly related to obesity itself, and cannot be considered a functional abnormality.
Therefore, we are unable to approve the requested procedures for reimbursement. We suggest that the patient consult with a physician who can determine whether the requested procedures are truly medically necessary and will improve functional abnormalities, and who can discuss alternative treatment options that may be covered under their insurance policy.
Grounds for denial: Not Medical Necessity[/INST] | The treatment is considered medically necessary because the I enrolled for excision of excess skin and subcutaneous tissue in different areas of the body. The physician reviewed the case and determined that the overlapping of the breasts in the photographs and clinically documented was a result of my obesity, which is considered a disease. The treatment of the breasts with a mastopexy is an effort to improve function and create a more normal appearance, which is medically necessary. | The treatment is considered medically necessary because the I enrolled for excision of excess skin and subcutaneous tissue in different areas of the body. The physician reviewed the case and determined that the overlapping of the breasts in the photographs and clinically documented was a result of my obesity, which is considered a disease. The treatment of the breasts with a mastopexy is an effort to improve function and create a more normal appearance, which is medically necessary. |
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Synthetic Appeals Data
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Synthetically generated health insurance appeal-related data + health insurance-related summarization type data. No warranty is expressed or implied. Generated from https://github.com/totallylegitco/healthinsurance-llm
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