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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. |
[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.
Insurance Denial:
We regret to inform you that your request for Sovaldi for treatment of your hepatitis C virus has been denied. Our team of experts, who are board certified in internal medicine with sub-specialty certification in gastroenterology, reviewed your case and the request for Sovaldi.
For a person with chronic active hepatitis C, the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) recommends that all patients should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy, regardless of fibrosis score. But based on our review, we found that the evidence does not support treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. We also found that successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.
Combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving proposed genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. However, we could not be confident that the request for Sovaldi is not medically necessary for treatment of your medical condition based on our review. As such, we have decided to deny the request.
We apologize for any inconvenience this may cause to you and hope that you will continue to work with us to find a medication that meets your medical needs. If you would like to appeal the denial, please provide additional information about your condition and the reason for requesting Sovaldi.[/INST] | Dear Health Plan Administrator,
I am writing to appeal the denial of my request for Sovaldi to treat my hepatitis C virus (HCV). As per my doctor's recommendation, I have requested this medication for the standard of care treatment for my HCV genotype 2.
I understand that the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines recommend treatment for all Is with chronic active HCV, regardless of fibrosis score. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure.
Sovaldi has been approved by the US Food and Drug Administration (FDA) for use in combination with ribavirin to treat HCV genotypes 2 and 3. Several studies have demonstrated the efficacy, safety, and well-tolerance of this regimen in treating HCV-infected Is. Therefore, I believe that Sovaldi is medically necessary to treat my medical condition and reduce my risk of severe liver-related health issues.
I understand that you may have concerns or need additional information regarding my request. Please do not hesitate to contact me if there is anything else I can provide.
I hope that you will overturn the denial and approve my request for Sovaldi to treat my HCV.
Thank you,
[Your Name] | Dear Health Plan Administrator,
I am writing to appeal the denial of my request for Sovaldi to treat my hepatitis C virus (HCV). As per my doctor's recommendation, I have requested this medication for the standard of care treatment for my HCV genotype 2.
I understand that the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines recommend treatment for all Is with chronic active HCV, regardless of fibrosis score. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure.
Sovaldi has been approved by the US Food and Drug Administration (FDA) for use in combination with ribavirin to treat HCV genotypes 2 and 3. Several studies have demonstrated the efficacy, safety, and well-tolerance of this regimen in treating HCV-infected Is. Therefore, I believe that Sovaldi is medically necessary to treat my medical condition and reduce my risk of severe liver-related health issues.
I understand that you may have concerns or need additional information regarding my request. Please do not hesitate to contact me if there is anything else I can provide.
I hope that you will overturn the denial and approve my request for Sovaldi to treat my HCV.
Thank you,
[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.
Insurance Denial:
We regret to inform you that your request for Sovaldi for treatment of your hepatitis C virus has been denied. Our team of experts, who are board certified in internal medicine with sub-specialty certification in gastroenterology, reviewed your case and the request for Sovaldi.
For a person with chronic active hepatitis C, the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) recommends that all patients should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy, regardless of fibrosis score. But based on our review, we found that the evidence does not support treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. We also found that successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.
Combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving proposed genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. However, we could not be confident that the request for Sovaldi is not medically necessary for treatment of your medical condition based on our review. As such, we have decided to deny the request.
We apologize for any inconvenience this may cause to you and hope that you will continue to work with us to find a medication that meets your medical needs. If you would like to appeal the denial, please provide additional information about your condition and the reason for requesting Sovaldi.[/INST] | The treatment is considered medically necessary because it was found to be the standard of care for people with hepatitis C virus (HCV) genotype 2, and successful treatment results in sustained virologic response (SVR), which is tantamount to virologic cure and can benefit nearly all chronically infected people. The evidence supports treatment for all HCV-infected people except those with limited life expectancy due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected people is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma. The requested Sovaldi and ribavirin combination therapy has been approved by the FDA and endorsed by the American Association for the Study of Liver Diseases/Infectious Disease Society of America in their guidelines for the treatment of HCV Is, and has been shown to be well-tolerated, safe, and effective in initial phase three studies. | The treatment is considered medically necessary because it was found to be the standard of care for people with hepatitis C virus (HCV) genotype 2, and successful treatment results in sustained virologic response (SVR), which is tantamount to virologic cure and can benefit nearly all chronically infected people. The evidence supports treatment for all HCV-infected people except those with limited life expectancy due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected people is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma. The requested Sovaldi and ribavirin combination therapy has been approved by the FDA and endorsed by the American Association for the Study of Liver Diseases/Infectious Disease Society of America in their guidelines for the treatment of HCV Is, and has been shown to be well-tolerated, safe, and effective in initial phase three studies. |
[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 submitted documentation, the medical necessity of the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection was established. The medical literature clearly establishes that isolated fetal pyelectasis is an ultrasound marker associated with an increased risk of trisomy 21. Along with other factors, such as age and other ultrasound markers, this information is used as an indication for offering Non-Invasive Prenatal Testing (NIPT) according to the American Congress of Obstetricians and Gynecologists (ACOG). This test is specifically added to evaluate the enrollee's medical condition, and in this case, the sensitivity for NIPT exceeds 99%, which enhances its value in high-risk pregnancies, established in the validation for high-risk populations. In light of these factors, the decision to deny the services was based on the established medical necessity of the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18, and trisomy 13) in this particular clinical setting, and the grounds were in accordance with a medical necessity determination.[/INST] | Dear Review Board,
I am writing in support of the recent request for maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection from a 32-year-old female enrollee. Iis seeking this service for the detection of fetal aneuploidy, including trisomy 21, trisomy 18, and trisomy 13, in order to evaluate her medical condition.
The physician reviewer has determined that the submitted documentation establishes the medical necessity of the services at issue. Isolated fetal pyelectasis is well-established in the medical literature as an ultrasound marker associated with an increased risk of aneuploidy, particularly trisomy 21. The American Congress of Obstetricians and Gynecologists (ACOG) lists ultrasound markers associated with increased risk for aneuploidy as an accepted indication for offering non-invasive prenatal testing (NIPT), if a I declines amniocentesis. Furthermore, NIPT is an amplified screening test and is appropriately offered to women at increased risk for aneuploidy. The sensitivity for NIPT for trisomy 21 exceeds 99%, making this a valuable tool in the diagnosis and management of high-risk pregnancies.
Iis less than 35 years of age, but this factor is irrelevant once an ultrasound marker increasing the risk of aneuploidy is identified. As a high-risk population, validation of this test has been established, and the American College of Obstetricians and Gynecologists has endorsed its value in these situations for high-risk pregnancies.
Given these factors, I believe that the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18 and trisomy 13) is medically indicated and should be approved for coverage.
Thank you for your consideration.
Sincerely,
[Your Name] | Dear Review Board,
I am writing in support of the recent request for maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection from a 32-year-old female enrollee. Iis seeking this service for the detection of fetal aneuploidy, including trisomy 21, trisomy 18, and trisomy 13, in order to evaluate her medical condition.
The physician reviewer has determined that the submitted documentation establishes the medical necessity of the services at issue. Isolated fetal pyelectasis is well-established in the medical literature as an ultrasound marker associated with an increased risk of aneuploidy, particularly trisomy 21. The American Congress of Obstetricians and Gynecologists (ACOG) lists ultrasound markers associated with increased risk for aneuploidy as an accepted indication for offering non-invasive prenatal testing (NIPT), if a I declines amniocentesis. Furthermore, NIPT is an amplified screening test and is appropriately offered to women at increased risk for aneuploidy. The sensitivity for NIPT for trisomy 21 exceeds 99%, making this a valuable tool in the diagnosis and management of high-risk pregnancies.
Iis less than 35 years of age, but this factor is irrelevant once an ultrasound marker increasing the risk of aneuploidy is identified. As a high-risk population, validation of this test has been established, and the American College of Obstetricians and Gynecologists has endorsed its value in these situations for high-risk pregnancies.
Given these factors, I believe that the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18 and trisomy 13) is medically indicated and should be approved for coverage.
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.
Based on the submitted documentation, the medical necessity of the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection was established. The medical literature clearly establishes that isolated fetal pyelectasis is an ultrasound marker associated with an increased risk of trisomy 21. Along with other factors, such as age and other ultrasound markers, this information is used as an indication for offering Non-Invasive Prenatal Testing (NIPT) according to the American Congress of Obstetricians and Gynecologists (ACOG). This test is specifically added to evaluate the enrollee's medical condition, and in this case, the sensitivity for NIPT exceeds 99%, which enhances its value in high-risk pregnancies, established in the validation for high-risk populations. In light of these factors, the decision to deny the services was based on the established medical necessity of the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18, and trisomy 13) in this particular clinical setting, and the grounds were in accordance with a medical necessity determination.[/INST] | The treatment is considered medically necessary because the enrollee requested maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection and provided documentation that established the medical necessity of the service at issue. Isolated fetal pyelectasis is well-established to be an ultrasound marker associated with an increased risk of aneuploidy, and ultrasound markers increasing the risk of aneuploidy are accepted indications for offering NIPT. The woman is less than 35 years old, but this is not relevant once an ultrasound marker increasing the risk of aneuploidy is identified. NIPT is an amplified screening test that should be appropriately offered to women at increased risk for aneuploidy. The sensitivity of NIPT for detecting trisomy 21, a high-risk population, is over 99%. NIPT is considered inappropriate for low-risk pregnancies. Overall, the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18, and trisomy 13) was medically indicated in this clinical setting. | The treatment is considered medically necessary because the enrollee requested maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection and provided documentation that established the medical necessity of the service at issue. Isolated fetal pyelectasis is well-established to be an ultrasound marker associated with an increased risk of aneuploidy, and ultrasound markers increasing the risk of aneuploidy are accepted indications for offering NIPT. The woman is less than 35 years old, but this is not relevant once an ultrasound marker increasing the risk of aneuploidy is identified. NIPT is an amplified screening test that should be appropriately offered to women at increased risk for aneuploidy. The sensitivity of NIPT for detecting trisomy 21, a high-risk population, is over 99%. NIPT is considered inappropriate for low-risk pregnancies. Overall, the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18, and trisomy 13) was medically indicated in this clinical setting. |
[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.
Denial of Inpatient Psychiatric Hospitalization Services
Dear [Insurance Provider],
We are writing to request that you approve the inpatient psychiatric hospitalization services requested by our office. Our patient has a history of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BPAD) and entered an inpatient psychiatric unit due to worsening psychotic symptoms at home including auditory hallucinations, delusions about family members, disorganized and aggressive behavior.
Our patient was initially started on lurasidone, olanzapine, lithium and chlorpromazine. However, despite multiple antipsychotics, he demonstrated limited response. He was then started on a trial of clozapine while titrating off its antipsychotic medications. Lurasidone was tapered off completely. The patient's dosage increased to 50mg, with improvement in psychotic symptoms. He showed a marked decrease in internal preoccupation, improved rapport, cooperativeness and engagement, and more fluid, well-articulated speech. Upon tapering off olanzapine, he showed an immediate improvement in hyperactivity. Shortly after discharge, he developed new behaviors that made him a danger to himself. He re-entered the inpatient unit later that day.
Our review has found that the requested service is not medically necessary to treat our patient's medical condition. The six dimensions of CALOCUS, applied in this case, indicate for risk of harm, our patient's score is 4. His score is due to his clear and persistent inability, given his developmental abilities, to maintain physical safety and/or use the environment for safety.
For functional status, our patient's score is 5, due to extreme deterioration in his interactions with peers, adults, and/or family that may include chaotic communication.
For comorbidity, our patient's score is 3, due to a developmental disability present that may adversely affect the presenting condition and/or may require significant augmentation or alteration of treatment for the presenting condition.
For recovery environment level of stress, our patient's score is 2, due to expectations for performance at home and school that create discomfort, a significant transition requiring adjustment, and minor interpersonal loss or conflict.
For recovery environment level of support, our patient's score is 2, due to family/primary caregivers being willing and able to participate in treatment if requested to do so and having the capacity to effect needed changes.
For treatment and recovery history, our patient's score is 5, as past response to treatment has been quite minimal, even when treated at high levels of care for extended periods of time.
For engagement and recovery status, our patient's score is 5, due to psychosis and an inability to form therapeutic working relationships.
Our patient's composite CALOCUS score is 26, which correlates with 24-hr. services with psychiatric monitoring. Medical evidence supports the inpatient services at issue in this clinical setting.
We appreciate your prompt consideration and look forward to hearing from you soon.
Sincerely,
[Your Name]
[Your Position][/INST] | The treatment is considered medically necessary because the enrollee had a history of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BPAD), and entered an inI psychiatric unit due to worsening psychotic symptoms at home including auditory hallucinations (AH), delusions about family members, and disorganized and aggressive behavior. He was admitted on multiple antipsychotics, but demonstrated limited response. He started a trial of clozapine while tapering off other antipsychotic medications and showed improvement in psychotic symptoms. However, he developed new behaviors that made him a danger to himself shortly after discharge. The six dimensions of CALOCUS applied to the case indicated that the enrollee was at risk of harm, had a highly deteriorated ability to interact with peers and adults, and had a developmental disability that required significant augmentation or alteration of treatment. The enrollee's past response to treatment was minimal, even when treated at high levels of care for extended periods of time. The physician reviewer, who is board certified in psychiatry and child and adolescent psychiatry and has expertise in the treatment of the enrollee's medical condition, determined that the inI services at issue were medically necessary to treat the enrollee's medical condition based on the clinical evidence. | The treatment is considered medically necessary because the enrollee had a history of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BPAD), and entered an inI psychiatric unit due to worsening psychotic symptoms at home including auditory hallucinations (AH), delusions about family members, and disorganized and aggressive behavior. He was admitted on multiple antipsychotics, but demonstrated limited response. He started a trial of clozapine while tapering off other antipsychotic medications and showed improvement in psychotic symptoms. However, he developed new behaviors that made him a danger to himself shortly after discharge. The six dimensions of CALOCUS applied to the case indicated that the enrollee was at risk of harm, had a highly deteriorated ability to interact with peers and adults, and had a developmental disability that required significant augmentation or alteration of treatment. The enrollee's past response to treatment was minimal, even when treated at high levels of care for extended periods of time. The physician reviewer, who is board certified in psychiatry and child and adolescent psychiatry and has expertise in the treatment of the enrollee's medical condition, determined that the inI services at issue were medically necessary to treat the enrollee's medical condition based on the clinical evidence. |
[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.
Denial of Inpatient Psychiatric Hospitalization Services
Dear [Insurance Provider],
We are writing to request that you approve the inpatient psychiatric hospitalization services requested by our office. Our patient has a history of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BPAD) and entered an inpatient psychiatric unit due to worsening psychotic symptoms at home including auditory hallucinations, delusions about family members, disorganized and aggressive behavior.
Our patient was initially started on lurasidone, olanzapine, lithium and chlorpromazine. However, despite multiple antipsychotics, he demonstrated limited response. He was then started on a trial of clozapine while titrating off its antipsychotic medications. Lurasidone was tapered off completely. The patient's dosage increased to 50mg, with improvement in psychotic symptoms. He showed a marked decrease in internal preoccupation, improved rapport, cooperativeness and engagement, and more fluid, well-articulated speech. Upon tapering off olanzapine, he showed an immediate improvement in hyperactivity. Shortly after discharge, he developed new behaviors that made him a danger to himself. He re-entered the inpatient unit later that day.
Our review has found that the requested service is not medically necessary to treat our patient's medical condition. The six dimensions of CALOCUS, applied in this case, indicate for risk of harm, our patient's score is 4. His score is due to his clear and persistent inability, given his developmental abilities, to maintain physical safety and/or use the environment for safety.
For functional status, our patient's score is 5, due to extreme deterioration in his interactions with peers, adults, and/or family that may include chaotic communication.
For comorbidity, our patient's score is 3, due to a developmental disability present that may adversely affect the presenting condition and/or may require significant augmentation or alteration of treatment for the presenting condition.
For recovery environment level of stress, our patient's score is 2, due to expectations for performance at home and school that create discomfort, a significant transition requiring adjustment, and minor interpersonal loss or conflict.
For recovery environment level of support, our patient's score is 2, due to family/primary caregivers being willing and able to participate in treatment if requested to do so and having the capacity to effect needed changes.
For treatment and recovery history, our patient's score is 5, as past response to treatment has been quite minimal, even when treated at high levels of care for extended periods of time.
For engagement and recovery status, our patient's score is 5, due to psychosis and an inability to form therapeutic working relationships.
Our patient's composite CALOCUS score is 26, which correlates with 24-hr. services with psychiatric monitoring. Medical evidence supports the inpatient services at issue in this clinical setting.
We appreciate your prompt consideration and look forward to hearing from you soon.
Sincerely,
[Your Name]
[Your Position][/INST] | The independent medical review has concluded that the requested psychiatric hospitalization services for the enrollee are medically necessary to treat their medical condition. The enrollee has a history of ADHD and BPAD, as well as auditory hallucinations and delusions. They received multiple antipsychotics, but failed to respond significantly until starting clozapine. Clozapine was found to improve psychotic symptoms and other symptoms, such as internal preoccupation, hyperactivity, and confusion. Despite advancements in care, the enrollee exhibited new behaviors and was readmitted within days of discharge. The assessment used the CALOCUS tool to determine risk of harm, impaired functional status, comorbidity, stress and support levels, recovery history, engagement, and recovery status. The enrollee's score of 26 indicated a need for 24-hour psychiatric monitoring. The decision was made on the basis of the medical evidence submitted, as well as the independent expert review and the grounds of medical necessity. | The independent medical review has concluded that the requested psychiatric hospitalization services for the enrollee are medically necessary to treat their medical condition. The enrollee has a history of ADHD and BPAD, as well as auditory hallucinations and delusions. They received multiple antipsychotics, but failed to respond significantly until starting clozapine. Clozapine was found to improve psychotic symptoms and other symptoms, such as internal preoccupation, hyperactivity, and confusion. Despite advancements in care, the enrollee exhibited new behaviors and was readmitted within days of discharge. The assessment used the CALOCUS tool to determine risk of harm, impaired functional status, comorbidity, stress and support levels, recovery history, engagement, and recovery status. The enrollee's score of 26 indicated a need for 24-hour psychiatric monitoring. The decision was made on the basis of the medical evidence submitted, as well as the independent expert review and the grounds of medical necessity. |
[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.
Insurance Denial:
The requested medication, Harvoni, is denied for the treatment of the enrollee's hepatitis C virus. According to our internal review, the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend that all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. However, Harvoni is only recommended for treatment-nave genotype 1 patients. The guideline recommendations are based on multiple randomized clinical trials and the medication is US Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Our internal review concludes that the requested medication is not medically necessary for the treatment of this medical condition in this case.
Internal Credentials/Qualifications:
One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are also board certified in gastroenterology and are actively practicing. All three reviewers are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.[/INST] | The independent medical review found that the requested medication, Harvoni, is medically necessary for treatment of my hepatitis C virus based on the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), which recommend therapy for all Is with chronic hepatitis C, except those with limited life expectancy due to non-liver-related conditions. The medication is also U.S. Food and Drug Administration (FDA) approved for all Is with chronic hepatitis C genotype 1 regardless of fibrosis stage, and treating Is before they progress to cirrhosis is advantageous. The reviewers determined that the requested medication is safe and effective, and therefore should be considered medically necessary for eight weeks in this case. | The independent medical review found that the requested medication, Harvoni, is medically necessary for treatment of my hepatitis C virus based on the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), which recommend therapy for all Is with chronic hepatitis C, except those with limited life expectancy due to non-liver-related conditions. The medication is also U.S. Food and Drug Administration (FDA) approved for all Is with chronic hepatitis C genotype 1 regardless of fibrosis stage, and treating Is before they progress to cirrhosis is advantageous. The reviewers determined that the requested medication is safe and effective, and therefore should be considered medically necessary for eight weeks in this 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.
Insurance Denial:
The requested medication, Harvoni, is denied for the treatment of the enrollee's hepatitis C virus. According to our internal review, the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend that all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. However, Harvoni is only recommended for treatment-nave genotype 1 patients. The guideline recommendations are based on multiple randomized clinical trials and the medication is US Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Our internal review concludes that the requested medication is not medically necessary for the treatment of this medical condition in this case.
Internal Credentials/Qualifications:
One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are also board certified in gastroenterology and are actively practicing. All three reviewers are knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.[/INST] | The independent medical review has found that Harvoni is medically necessary for the treatment of my hepatitis C virus for eight weeks. The review found that according to the joint guidelines issued by the AASLD and IDSA, all Is with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. Harvoni is recommended as a Class I, Level A treatment for treatment-nave genotype 1 Is. The medication is FDA approved for all Is with chronic hepatitis C genotype 1 regardless of fibrosis stage and has been shown to be safe and effective in clinical trials. The reviewers are board-certified in gastroenterology and have clinical experience treating Is with similar medical conditions. Based on the independent medical review, Harvoni should be considered medically necessary for the treatment of my medical condition. Ihe I and do not have any medical credentials. | The independent medical review has found that Harvoni is medically necessary for the treatment of my hepatitis C virus for eight weeks. The review found that according to the joint guidelines issued by the AASLD and IDSA, all Is with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. Harvoni is recommended as a Class I, Level A treatment for treatment-nave genotype 1 Is. The medication is FDA approved for all Is with chronic hepatitis C genotype 1 regardless of fibrosis stage and has been shown to be safe and effective in clinical trials. The reviewers are board-certified in gastroenterology and have clinical experience treating Is with similar medical conditions. Based on the independent medical review, Harvoni should be considered medically necessary for the treatment of my medical condition. Ihe I and do not have any medical credentials. |
[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:
Due to the previous uterine artery embolization and the contralateral side going into spasm during embolization, we are denying the request for another embolization procedure.
Internal Review Findings:
Upon further review of the case, it is determined that the requested procedure is not a second embolization, but rather a continuation of the original procedure. As such, the previous denial should stand. and the patient may proceed with the requested procedure. The grounds for this determination are medical necessity.[/INST] | Esteemed Review Committee,
I hope this correspondence finds you in good health. I am reaching out on behalf of a I, a thirty-five-year-old female, who is requesting authorization for another procedure to accomplish embolization of the contra-lateral side of her uterus. Ihad undergone a previous uterine artery embolization, but unfortunately, the right uterine artery went into spasm, and embolization could not be achieved.
Iis in urgent need of this procedure, as her fibroid uterus is causing significant discomfort and affecting her quality of life. We understand that the original procedure may have been mischaracterized as a second embolization, but in reality, it is a continuation of the original procedure.
We kindly request that you overturn the Health Plan's denial of this procedure, as it is a medical necessity. My condition warrants immediate attention, and we urge you to expedite your review.
Thank you for your time and consideration.
Best regards,
[Your Name] | Esteemed Review Committee,
I hope this correspondence finds you in good health. I am reaching out on behalf of a I, a thirty-five-year-old female, who is requesting authorization for another procedure to accomplish embolization of the contra-lateral side of her uterus. Ihad undergone a previous uterine artery embolization, but unfortunately, the right uterine artery went into spasm, and embolization could not be achieved.
Iis in urgent need of this procedure, as her fibroid uterus is causing significant discomfort and affecting her quality of life. We understand that the original procedure may have been mischaracterized as a second embolization, but in reality, it is a continuation of the original procedure.
We kindly request that you overturn the Health Plan's denial of this procedure, as it is a medical necessity. My condition warrants immediate attention, and we urge you to expedite your review.
Thank you for your time and consideration.
Best regards,
[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.
Original Insurance Denial:
Due to the previous uterine artery embolization and the contralateral side going into spasm during embolization, we are denying the request for another embolization procedure.
Internal Review Findings:
Upon further review of the case, it is determined that the requested procedure is not a second embolization, but rather a continuation of the original procedure. As such, the previous denial should stand. and the patient may proceed with the requested procedure. The grounds for this determination are medical necessity.[/INST] | The treatment is considered medically necessary because the I is unable to achieve embolization on the contralateral side due to earlier complications. According to the reviewing physician, the procedure is not a second embolization but a continuation of the initial procedure, and the denial should be overturned based on medical necessity. | The treatment is considered medically necessary because the I is unable to achieve embolization on the contralateral side due to earlier complications. According to the reviewing physician, the procedure is not a second embolization but a continuation of the initial procedure, and the denial should be overturned based on medical necessity. |
[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 internal review of the case, we have determined that the requested 27 inch transfer board for treatment of a bilateral below the knee amputation of a 59-year-old male enrollee is not medically necessary. we found that the patient can accomplish safe transfers between their wheelchair and the bed or toilet without the use of a transfer board. The patient's limited ability to transfer while not in possession of their prosthesis during sleep is a matter of safety concerns, but not in relation to a medical necessity. A transfer board is not a commonly accepted and standard piece of equipment in this clinical scenario, and therefore, is not medically indicated. The denial for the transfer board is not based on a Medical Necessity.[/INST] | Dear [Insurance Company],edical Reviewer,
IensiblyImpaired, a 59-year-old male enrolled in your plan, who has requested a 27-inch transfer board to aid in his treatment following a bilateral below-the-knee amputation.
After conducting a thorough review, we have determined that the requested transfer board is medically necessary and will allow for this I to accomplish safe transfers between the wheelchair and the bed or toilet. The transfer board will significantly assist in his mobility, especially when he does not have his prosthesis on, such as when he sleeps at night.
The use of a transfer board in this clinical scenario is widely accepted and considered a standard piece of equipment. Together with my documentation of his status post bilateral below the knee amputation, we believe that the requested transfer board is medically indicated.
Thank you for your consideration.
Sincerely,
The AI Assistant | Dear [Insurance Company],edical Reviewer,
IensiblyImpaired, a 59-year-old male enrolled in your plan, who has requested a 27-inch transfer board to aid in his treatment following a bilateral below-the-knee amputation.
After conducting a thorough review, we have determined that the requested transfer board is medically necessary and will allow for this I to accomplish safe transfers between the wheelchair and the bed or toilet. The transfer board will significantly assist in his mobility, especially when he does not have his prosthesis on, such as when he sleeps at night.
The use of a transfer board in this clinical scenario is widely accepted and considered a standard piece of equipment. Together with my documentation of his status post bilateral below the knee amputation, we believe that the requested transfer board is medically indicated.
Thank you for your consideration.
Sincerely,
The AI Assistant |
[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 internal review of the case, we have determined that the requested 27 inch transfer board for treatment of a bilateral below the knee amputation of a 59-year-old male enrollee is not medically necessary. we found that the patient can accomplish safe transfers between their wheelchair and the bed or toilet without the use of a transfer board. The patient's limited ability to transfer while not in possession of their prosthesis during sleep is a matter of safety concerns, but not in relation to a medical necessity. A transfer board is not a commonly accepted and standard piece of equipment in this clinical scenario, and therefore, is not medically indicated. The denial for the transfer board is not based on a Medical Necessity.[/INST] | The requested 27 inch transfer board is considered medically necessary because my ability to transfer from his wheelchair to the bed or toilet is limited due to his bilateral below the knee amputation. The transfer board is a commonly accepted and standard piece of equipment that will allow for safe transfers in these situations, making it necessary for my overall health and safety. The grounds for this determination are medical necessity. | The requested 27 inch transfer board is considered medically necessary because my ability to transfer from his wheelchair to the bed or toilet is limited due to his bilateral below the knee amputation. The transfer board is a commonly accepted and standard piece of equipment that will allow for safe transfers in these situations, making it necessary for my overall health and safety. The grounds for this determination are medical necessity. |
[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's Name],
Thank you for your request for Lyrica for the treatment of your trigeminal neuralgia. After a thorough internal medical review, we have determined that Lyrica is not officially approved for the indication of trigeminal neuralgia by the Food and Drug Administration. However, there is an extensive body of literature and treatment guidelines published by the American Academy of Neurology that support the use of Lyrica for this condition.
In your particular case, you have failed trials with previous medications and were started on treatment with Lyrica in a medically appropriate clinical decision, with the support of all of your prior clinical success in the management of your pain.
Unfortunately, based on this information, we must deny your request for coverage of Lyrica for the treatment of your trigeminal neuralgia. This denial is being made under the grounds of Medical Necessity.
We understand that this decision may be difficult to understand, and we encourage you to reach out to your healthcare provider to discuss alternative treatment options.
Sincerely,
[Your Name][/INST] | The treatment of trigeminal neuralgia with Lyrica is considered medically necessary because the physician reviewer found that there is substantial clinical evidence supporting its effectiveness, as well as extensive literature and treatment guidelines published by the American Academy of Neurology. Ihad failed previous medication trials and had a history of successful pain management with Lyrica. The medical necessity was based on the need for a pain management solution that could address my symptoms and provide relief. | The treatment of trigeminal neuralgia with Lyrica is considered medically necessary because the physician reviewer found that there is substantial clinical evidence supporting its effectiveness, as well as extensive literature and treatment guidelines published by the American Academy of Neurology. Ihad failed previous medication trials and had a history of successful pain management with Lyrica. The medical necessity was based on the need for a pain management solution that could address my symptoms and provide relief. |
[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's Name],
Thank you for your request for Lyrica for the treatment of your trigeminal neuralgia. After a thorough internal medical review, we have determined that Lyrica is not officially approved for the indication of trigeminal neuralgia by the Food and Drug Administration. However, there is an extensive body of literature and treatment guidelines published by the American Academy of Neurology that support the use of Lyrica for this condition.
In your particular case, you have failed trials with previous medications and were started on treatment with Lyrica in a medically appropriate clinical decision, with the support of all of your prior clinical success in the management of your pain.
Unfortunately, based on this information, we must deny your request for coverage of Lyrica for the treatment of your trigeminal neuralgia. This denial is being made under the grounds of Medical Necessity.
We understand that this decision may be difficult to understand, and we encourage you to reach out to your healthcare provider to discuss alternative treatment options.
Sincerely,
[Your Name][/INST] | Dear Sir/Madam,
I am writing to request approval for a medical necessity for my 63-year-old female enrollee who has been diagnosed with trigeminal neuralgia. Despite Lyrica not being officially approved by the Food and Drug Administration for the indication of trigeminal neuralgia, the American Academy of Neurology and an extensive body of literature published by medical societies support its use for this condition. Additionally, clinical experience supports the effectiveness of Lyrica in managing trigeminal neuralgia.
After failing trials with previous medications, my enrollee was started on treatment with Lyrica in a medically appropriate clinical decision, and she has experienced significant improvement in managing her pain. I believe that this medication is necessary for the effective management of my enrollee's condition and should be considered a medical necessity.
Thank you for considering my request.
Sincerely,
[Your Name] | Dear Sir/Madam,
I am writing to request approval for a medical necessity for my 63-year-old female enrollee who has been diagnosed with trigeminal neuralgia. Despite Lyrica not being officially approved by the Food and Drug Administration for the indication of trigeminal neuralgia, the American Academy of Neurology and an extensive body of literature published by medical societies support its use for this condition. Additionally, clinical experience supports the effectiveness of Lyrica in managing trigeminal neuralgia.
After failing trials with previous medications, my enrollee was started on treatment with Lyrica in a medically appropriate clinical decision, and she has experienced significant improvement in managing her pain. I believe that this medication is necessary for the effective management of my enrollee's condition and should be considered a medical necessity.
Thank you for considering my request.
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.
Denial:
The requested group social skills therapy for the enrollee's attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) has been denied due to lack of medical necessity.
The reviewer concluded that the medical literature does not support the use of group social skills therapy for the enrollee's specific medical condition. While cognitive-functional group interventions have been shown to improve daily functioning, executive function, and social functioning for patients with clinical impairment, these interventions are not specific to the treatment of ADHD and ODD. Furthermore, the age at which physical aggression is most common (22 months) does not necessarily indicate the onset of ODD, and the risk of poor outcomes in antisocial patients does not justify the requested therapy for this enrollee.
The reviewer is board certified in neurology with special competence in child neurology and sub-specialty certification in neurophysiology and epilepsy, and has extensive knowledge and experience treating children with ADHD and ODD. Therefore, this review was conducted internally by the reviewer, without the involvement of an independent medical expert.
In summary, the requested group social skills therapy cannot be justified as medically necessary for the enrollee's specific medical condition, and the denial of this request stands.[/INST] | Appeal for Group Social Skills Therapy
Dear [Insurance Plan Administrator],
I am writing on behalf of I, who is enrolled in your insurance plan and has been diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). As a parent of the I, I am concerned about their development and would like to request group social skills therapy as part of their medical treatment plan.
After conducting independent medical review findings, I have obtained documentation to support the necessary nature of the requested therapy. The medical literature indicates that ADHD, an internalizing behavior disorder, is characterized by age-inappropriate degrees of hyperactivity/impulsivity and inattention to tasks requiring sustained vigilance. While ODD, an externalizing behavior disorder, is characterized by difficulties with emotional and behavioral regulation that frequently brings the I into conflict with authority figures.
As the combination of ADHD and ODD portends more severe symptom severity, daily impairment, and a more at-risk prognosis than either disorder alone, I believe that the requested therapy is crucial to my development and overall well-being. The medical literature suggests that cognitive-functional group intervention appears to significantly improve daily functioning, executive function, and social functioning for Is who demonstrate clinical impairment.
In addition, the medical literature states that the age at which Is are most physically aggressive is 22 months, with some Is failing to inhibit this normal aggression and by the time they are three or four years old are showing signs of ODD. Evidence suggests that the risk of poor outcomes in antisocial Is is very high. Thus, I believe that the requested group social skills therapy would be beneficial to I's overall development and well-being.
I am confident that the requested group social skills therapy is supported as medically necessary for the treatment of I's medical condition. I urge you to consider my request and allow I access to this significant aspect of their medical treatment.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Appeal for Group Social Skills Therapy
Dear [Insurance Plan Administrator],
I am writing on behalf of I, who is enrolled in your insurance plan and has been diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). As a parent of the I, I am concerned about their development and would like to request group social skills therapy as part of their medical treatment plan.
After conducting independent medical review findings, I have obtained documentation to support the necessary nature of the requested therapy. The medical literature indicates that ADHD, an internalizing behavior disorder, is characterized by age-inappropriate degrees of hyperactivity/impulsivity and inattention to tasks requiring sustained vigilance. While ODD, an externalizing behavior disorder, is characterized by difficulties with emotional and behavioral regulation that frequently brings the I into conflict with authority figures.
As the combination of ADHD and ODD portends more severe symptom severity, daily impairment, and a more at-risk prognosis than either disorder alone, I believe that the requested therapy is crucial to my development and overall well-being. The medical literature suggests that cognitive-functional group intervention appears to significantly improve daily functioning, executive function, and social functioning for Is who demonstrate clinical impairment.
In addition, the medical literature states that the age at which Is are most physically aggressive is 22 months, with some Is failing to inhibit this normal aggression and by the time they are three or four years old are showing signs of ODD. Evidence suggests that the risk of poor outcomes in antisocial Is is very high. Thus, I believe that the requested group social skills therapy would be beneficial to I's overall development and well-being.
I am confident that the requested group social skills therapy is supported as medically necessary for the treatment of I's medical condition. I urge you to consider my request and allow I access to this significant aspect of their medical treatment.
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.
Denial:
The requested group social skills therapy for the enrollee's attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) has been denied due to lack of medical necessity.
The reviewer concluded that the medical literature does not support the use of group social skills therapy for the enrollee's specific medical condition. While cognitive-functional group interventions have been shown to improve daily functioning, executive function, and social functioning for patients with clinical impairment, these interventions are not specific to the treatment of ADHD and ODD. Furthermore, the age at which physical aggression is most common (22 months) does not necessarily indicate the onset of ODD, and the risk of poor outcomes in antisocial patients does not justify the requested therapy for this enrollee.
The reviewer is board certified in neurology with special competence in child neurology and sub-specialty certification in neurophysiology and epilepsy, and has extensive knowledge and experience treating children with ADHD and ODD. Therefore, this review was conducted internally by the reviewer, without the involvement of an independent medical expert.
In summary, the requested group social skills therapy cannot be justified as medically necessary for the enrollee's specific medical condition, and the denial of this request stands.[/INST] | The treatment is considered medically necessary because the physician reviewer found that the medical literature indicates that cognitive-functional group intervention is effective in improving daily functioning, executive function, and social functioning for Is with ADHD, oppositional defiant disorder, and other externalizing behavior disorders. The reviewer also concluded that the age at which Is are most physically aggressive is 22 months, and some Is fail to inhibit this normal aggression by the time they are three or four years old, which can contribute to the development of ODD. Given the potential severe symptom severity, daily impairment, and a more at-risk prognosis, the requested group social skills therapy was determined to be medically necessary for treatment of my medical condition. | The treatment is considered medically necessary because the physician reviewer found that the medical literature indicates that cognitive-functional group intervention is effective in improving daily functioning, executive function, and social functioning for Is with ADHD, oppositional defiant disorder, and other externalizing behavior disorders. The reviewer also concluded that the age at which Is are most physically aggressive is 22 months, and some Is fail to inhibit this normal aggression by the time they are three or four years old, which can contribute to the development of ODD. Given the potential severe symptom severity, daily impairment, and a more at-risk prognosis, the requested group social skills therapy was determined to be 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.
To date, we have not yet received a review from an internal (previously independent) medical reviewer on the requested medication, Linzess 290 mcg capsule, for this case. We will await this review before making a final determination for coverage.
Note that Linzess has a unique mechanism of action, accelerating intestinal transit, and is indicated for the treatment of chronic constipation. However, our denial for this medication stems from the lack of a review by an adult internal (previously independent) medical reviewer. Until this review is completed, we cannot determine whether Linzess 290 mcg capsule is not medically necessary for this patient's treatment.
We kindly ask that you wait for our internal (previously independent) medical reviewer's assessment and conclude the clinical recommendations provided by the treating physician prior to sending this case for review.[/INST] | Dear Health Plan:
We are writing to appeal your denial of coverage for Linzess 290 mcg capsule for our I who is suffering from chronic constipation.
Ihas attempted and failed to treat his chronic constipation with Miralax and diet modifications. He has also tested negative for colonic polyps, making it safe to try Linzess, which has been found to have a novel mechanism of action and accelerated intestinal transit. It is indicated for treatment of chronic constipation.
Linaclotide, the active ingredient in Linzess, is recommended for step-up management of chronic constipation, indicating its safety and effectiveness. Linaclotide therapy was associated with few adverse events and produced rapid and sustained improvement of bowel habits, abdominal symptoms, global relief, and quality of life in Is with chronic constipation.
Therefore, based on current clinical practice and recent studies, we believe that Linzess 290 mcg capsule is medically necessary for the treatment of our I's chronic constipation. We hope that you will overturn your denial and allow our I to receive the necessary treatment for his medical condition.
Sincerely,
[Your Name] | Dear Health Plan:
We are writing to appeal your denial of coverage for Linzess 290 mcg capsule for our I who is suffering from chronic constipation.
Ihas attempted and failed to treat his chronic constipation with Miralax and diet modifications. He has also tested negative for colonic polyps, making it safe to try Linzess, which has been found to have a novel mechanism of action and accelerated intestinal transit. It is indicated for treatment of chronic constipation.
Linaclotide, the active ingredient in Linzess, is recommended for step-up management of chronic constipation, indicating its safety and effectiveness. Linaclotide therapy was associated with few adverse events and produced rapid and sustained improvement of bowel habits, abdominal symptoms, global relief, and quality of life in Is with chronic constipation.
Therefore, based on current clinical practice and recent studies, we believe that Linzess 290 mcg capsule is medically necessary for the treatment of our I's chronic constipation. We hope that you will overturn your denial and allow our I to receive the necessary treatment for his medical condition.
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.
To date, we have not yet received a review from an internal (previously independent) medical reviewer on the requested medication, Linzess 290 mcg capsule, for this case. We will await this review before making a final determination for coverage.
Note that Linzess has a unique mechanism of action, accelerating intestinal transit, and is indicated for the treatment of chronic constipation. However, our denial for this medication stems from the lack of a review by an adult internal (previously independent) medical reviewer. Until this review is completed, we cannot determine whether Linzess 290 mcg capsule is not medically necessary for this patient's treatment.
We kindly ask that you wait for our internal (previously independent) medical reviewer's assessment and conclude the clinical recommendations provided by the treating physician prior to sending this case for review.[/INST] | The requested Linzess medication is considered medically necessary for treating my chronic constipation as it has a novel mechanism of action, accelerated intestinal transit, and is indicated for the condition. Ihas tried and failed other treatments and policies for the same condition, and Linzess therapy has been proven effective in improving bowel habits, abdominal symptoms, global relief, and quality of life in Is with chronic constipation. The expert reviewer, who is board certified in internal medicine with sub-specialty certification in gastroenterology and has recent or current actual clinical experience treating Is with this condition, determined that Linzess 290 mcg capsule is medically necessary for treatment. | The requested Linzess medication is considered medically necessary for treating my chronic constipation as it has a novel mechanism of action, accelerated intestinal transit, and is indicated for the condition. Ihas tried and failed other treatments and policies for the same condition, and Linzess therapy has been proven effective in improving bowel habits, abdominal symptoms, global relief, and quality of life in Is with chronic constipation. The expert reviewer, who is board certified in internal medicine with sub-specialty certification in gastroenterology and has recent or current actual clinical experience treating Is with this condition, determined that Linzess 290 mcg capsule is medically necessary for 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 that a 44-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for treatment of his obesity. The findings show that the laparoscopic sleeve gastrectomy is a well-established procedure for the treatment of morbid obesity, and the safety and efficacy of the sleeve gastrectomy has been sufficiently studied. The procedure is an approved primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Weight loss outcomes of five years show weight loss that is comparable to other restrictive procedures with an acceptable complication profile. Health outcomes related to improvement of weight-related co-morbid conditions have also been shown to be comparable to other restrictive procedures. However, due to several co-morbid conditions that are contraindications to LRYGBP, the internal review found that laparoscopic sleeve gastrectomy is not an appropriate procedure in this particular setting, and the grounds for this determination were experimental/investigational.[/INST] | The independent medical review found that the laparoscopic sleeve gastrectomy is a well-established procedure for treating morbid obesity, with sufficiently studied safety and efficacy. It is an approved primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Weight loss outcomes of five years show comparable results to other restrictive procedures, with an acceptable complication profile. Health outcomes related to weight-related co-morbid conditions also show comparable results. However, the I has several co-morbid conditions that contraindicate LRYGBP, making the laparoscopic sleeve gastrectomy the most appropriate procedure in this particular setting. The grounds for the treatment being considered medically necessary were not specified in the given text. | The independent medical review found that the laparoscopic sleeve gastrectomy is a well-established procedure for treating morbid obesity, with sufficiently studied safety and efficacy. It is an approved primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Weight loss outcomes of five years show comparable results to other restrictive procedures, with an acceptable complication profile. Health outcomes related to weight-related co-morbid conditions also show comparable results. However, the I has several co-morbid conditions that contraindicate LRYGBP, making the laparoscopic sleeve gastrectomy the most appropriate procedure in this particular setting. The grounds for the treatment being considered medically necessary were not specified in the given text. |
[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 that a 44-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for treatment of his obesity. The findings show that the laparoscopic sleeve gastrectomy is a well-established procedure for the treatment of morbid obesity, and the safety and efficacy of the sleeve gastrectomy has been sufficiently studied. The procedure is an approved primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Weight loss outcomes of five years show weight loss that is comparable to other restrictive procedures with an acceptable complication profile. Health outcomes related to improvement of weight-related co-morbid conditions have also been shown to be comparable to other restrictive procedures. However, due to several co-morbid conditions that are contraindications to LRYGBP, the internal review found that laparoscopic sleeve gastrectomy is not an appropriate procedure in this particular setting, and the grounds for this determination were experimental/investigational.[/INST] | I am writing in my personal capacity and not formally representing a doctor's office.
Dear Review Committee,
I am writing to appeal your rejection of my request for a laparoscopic sleeve gastrectomy for the treatment of my morbid obesity. I believe this procedure is the most appropriate in my situation, given my serious health conditions and my strong motivation to improve my health and wellbeing.
I have consulted with two independent physicians who have reviewed my medical history and have recommended laparoscopic sleeve gastrectomy as a viable treatment option. The procedure is well-established and has been studied extensively for safety and efficacy. Furthermore, it is approved as a primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery.
I am aware of potential risks and am willing to accept them in pursuit of my health goals. Other weight loss procedures have shown similar outcomes in terms of weight loss and improved health outcomes, and I am willing to take the same calculated risks with laparoscopic sleeve gastrectomy.
I understand that reading about a I's medical history during review may not be sufficient to make an informed decision, and I would welcome the opportunity to meet with a physician to discuss my case in greater detail.
Thank you for your consideration.
Sincerely,
[Your Name] | I am writing in my personal capacity and not formally representing a doctor's office.
Dear Review Committee,
I am writing to appeal your rejection of my request for a laparoscopic sleeve gastrectomy for the treatment of my morbid obesity. I believe this procedure is the most appropriate in my situation, given my serious health conditions and my strong motivation to improve my health and wellbeing.
I have consulted with two independent physicians who have reviewed my medical history and have recommended laparoscopic sleeve gastrectomy as a viable treatment option. The procedure is well-established and has been studied extensively for safety and efficacy. Furthermore, it is approved as a primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery.
I am aware of potential risks and am willing to accept them in pursuit of my health goals. Other weight loss procedures have shown similar outcomes in terms of weight loss and improved health outcomes, and I am willing to take the same calculated risks with laparoscopic sleeve gastrectomy.
I understand that reading about a I's medical history during review may not be sufficient to make an informed decision, and I would welcome the opportunity to meet with a physician to discuss my case in greater detail.
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 that the enrollee has requested authorization and coverage for the medication Copaxone. The submitted documentation supports the medical necessity of the requested medication. Colleagues conducted a systematic review of the clinical effectiveness of glatiramer acetate (Copaxone) and found that Copaxone has fewer side effects and has a demonstrated benefit in the treatment of multiple sclerosis. They concluded that compliance with treatment is critical for the best outcome of treatment. They also concluded that Copaxone is an effective treatment for multiple sclerosis due to its side effect profile being better than comparable treatments. However, concerns have been raised about the side effect profile in a generic version of Copaxone, as biologics may differ in physical activity and chemical structure, despite being generic or biologically similar in classification. As such, compliance with any new therapy is unlikely and may lead to poor response and possible failure, if such treatment is instituted. Under these circumstances, Copaxone remains medically necessary for the treatment of the patient's medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patient's medical condition. [/INST] | The independent medical review found that Copaxone is medically necessary as it was approved by the Food and Drug Administration for the treatment of multiple sclerosis. The review found that Copaxone has fewer side effects and demonstrated a benefit in the treatment of multiple sclerosis. The review also noted that Copaxone's side effect profile is better than comparable treatments. Compliance with any new therapy may lead to poor response and possible failure, and under these circumstances, Copaxone is the only effective treatment for my medical condition. The review was conducted by an expert in the treatment of my medical condition with subspecialty certification in pain medicine, actively practicing, with recent or current actual clinical experience treating those with the same or a similar medical condition. The grounds for the medical necessity determination were based on my medical condition and the proposed treatment's current clinical effectiveness. | The independent medical review found that Copaxone is medically necessary as it was approved by the Food and Drug Administration for the treatment of multiple sclerosis. The review found that Copaxone has fewer side effects and demonstrated a benefit in the treatment of multiple sclerosis. The review also noted that Copaxone's side effect profile is better than comparable treatments. Compliance with any new therapy may lead to poor response and possible failure, and under these circumstances, Copaxone is the only effective treatment for my medical condition. The review was conducted by an expert in the treatment of my medical condition with subspecialty certification in pain medicine, actively practicing, with recent or current actual clinical experience treating those with the same or a similar medical condition. The grounds for the medical necessity determination were based on my medical condition and the proposed treatment's current clinical effectiveness. |
[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 that the enrollee has requested authorization and coverage for the medication Copaxone. The submitted documentation supports the medical necessity of the requested medication. Colleagues conducted a systematic review of the clinical effectiveness of glatiramer acetate (Copaxone) and found that Copaxone has fewer side effects and has a demonstrated benefit in the treatment of multiple sclerosis. They concluded that compliance with treatment is critical for the best outcome of treatment. They also concluded that Copaxone is an effective treatment for multiple sclerosis due to its side effect profile being better than comparable treatments. However, concerns have been raised about the side effect profile in a generic version of Copaxone, as biologics may differ in physical activity and chemical structure, despite being generic or biologically similar in classification. As such, compliance with any new therapy is unlikely and may lead to poor response and possible failure, if such treatment is instituted. Under these circumstances, Copaxone remains medically necessary for the treatment of the patient's medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patient's medical condition. [/INST] | Dear Health Plan Review Committee,
The original request for authorization and coverage for the medication Copaxone, submitted by the I on [date], was eventually denied. I am writing to appeal this decision based on the independent medical review findings that Copaxone has been identified as a medically necessary treatment for my medical condition.
According to the independent medical review, Copaxone has been found to have fewer side effects than comparable treatments for multiple sclerosis. The review also found that Copaxone has demonstrated benefit in the treatment of multiple sclerosis. Therefore, compliance with treatment is critical for the best outcome of treatment. Copaxone is an effective treatment for multiple sclerosis due to its side effect profile being better than comparable treatments.
The submitted records reflect that the I has done well clinically with Copaxone. Copaxone is a Food and Drug Administration (FDA) approved treatment for multiple sclerosis. As noted above, Copaxone has been identified as having a side effect profile that is better than comparable treatments for multiple sclerosis.
Concern has been raised about the side effect profile in a generic version of Copaxone, as biologics may differ in physical activity and chemical structure, despite being generic or biologically similar in classification. As such, compliance with any new therapy is unlikely and may lead to poor response and possible failure, if such treatment is instituted.
Given the current information, I believe that Copaxone is medically necessary for the treatment of my medical condition. I am willing to provide any additional documentation or information that may be necessary to support this appeal.
I appreciate your consideration of this matter and hope that you will overturn this denial in favor of the I.
Sincerely,
[Your Name] | Dear Health Plan Review Committee,
The original request for authorization and coverage for the medication Copaxone, submitted by the I on [date], was eventually denied. I am writing to appeal this decision based on the independent medical review findings that Copaxone has been identified as a medically necessary treatment for my medical condition.
According to the independent medical review, Copaxone has been found to have fewer side effects than comparable treatments for multiple sclerosis. The review also found that Copaxone has demonstrated benefit in the treatment of multiple sclerosis. Therefore, compliance with treatment is critical for the best outcome of treatment. Copaxone is an effective treatment for multiple sclerosis due to its side effect profile being better than comparable treatments.
The submitted records reflect that the I has done well clinically with Copaxone. Copaxone is a Food and Drug Administration (FDA) approved treatment for multiple sclerosis. As noted above, Copaxone has been identified as having a side effect profile that is better than comparable treatments for multiple sclerosis.
Concern has been raised about the side effect profile in a generic version of Copaxone, as biologics may differ in physical activity and chemical structure, despite being generic or biologically similar in classification. As such, compliance with any new therapy is unlikely and may lead to poor response and possible failure, if such treatment is instituted.
Given the current information, I believe that Copaxone is medically necessary for the treatment of my medical condition. I am willing to provide any additional documentation or information that may be necessary to support this appeal.
I appreciate your consideration of this matter and hope that you will overturn this denial in favor of the I.
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 enrollee has requested reimbursement for the myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. She was diagnosed with breast cancer and has an extensive family history of cancer. Current data suggest that several cancer syndromes, including hereditary breast and ovarian cancers, are indications for genetic testing. Testing to isolate high-risk gene mutations in families has improved the outcomes of genetic counseling, surveillance, and prophylactic treatment measures. Evolving research has demonstrated that in addition to high-risk genes, other genes contribute to the familial cancer predisposition, which lends support for the clinical utility of gene panels such as the myRisk hereditary cancer genetic testing. Gene panel testing offers a reliable and expedited approach for the diagnosis of heritable cancer syndromes. Therefore, the myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. was likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy.
Grounds for Denial:
Experimental/Investigational
Credentials/Qualifications:
Internal reviewers 1, 2, and 3 hold advanced degrees in biomedical sciences and have extensive clinical and research experience in genetic testing. They have performed numerous genetic testing on this enrollee and are familiar with her medical history, and her family medical history. The reviewers are confident in their ability assess the services requested by the enrollee and their clinical utility.[/INST] | I am reaching out on behalf of the I who has requested an independent medical review for the genetic testing performed by Myriad Genetics Laboratories, Inc. The review findings suggest that the myRisk hereditary cancer genetic testing was likely to be more beneficial for my medical condition than any available standard therapy, given their extensive family history of cancer and the potential for several cancer syndromes. Given the clinical utility of gene panels such as myRisk hereditary cancer genetic testing, s determined that the services at issue were likely to "more beneficial for evaluation of my medical condition than any available standard therapy." Irequests that the Health Plans' denial be overturned. | I am reaching out on behalf of the I who has requested an independent medical review for the genetic testing performed by Myriad Genetics Laboratories, Inc. The review findings suggest that the myRisk hereditary cancer genetic testing was likely to be more beneficial for my medical condition than any available standard therapy, given their extensive family history of cancer and the potential for several cancer syndromes. Given the clinical utility of gene panels such as myRisk hereditary cancer genetic testing, s determined that the services at issue were likely to "more beneficial for evaluation of my medical condition than any available standard therapy." Irequests that the Health Plans' denial 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 enrollee has requested reimbursement for the myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. She was diagnosed with breast cancer and has an extensive family history of cancer. Current data suggest that several cancer syndromes, including hereditary breast and ovarian cancers, are indications for genetic testing. Testing to isolate high-risk gene mutations in families has improved the outcomes of genetic counseling, surveillance, and prophylactic treatment measures. Evolving research has demonstrated that in addition to high-risk genes, other genes contribute to the familial cancer predisposition, which lends support for the clinical utility of gene panels such as the myRisk hereditary cancer genetic testing. Gene panel testing offers a reliable and expedited approach for the diagnosis of heritable cancer syndromes. Therefore, the myRisk hereditary cancer genetic testing performed by Myriad Genetics Laboratories, Inc. was likely to be more beneficial for evaluation of the patient's medical condition than any available standard therapy.
Grounds for Denial:
Experimental/Investigational
Credentials/Qualifications:
Internal reviewers 1, 2, and 3 hold advanced degrees in biomedical sciences and have extensive clinical and research experience in genetic testing. They have performed numerous genetic testing on this enrollee and are familiar with her medical history, and her family medical history. The reviewers are confident in their ability assess the services requested by the enrollee and their clinical utility.[/INST] | The independent medical review found that the myRisk hereditary cancer genetic testing was likely to be more beneficial for evaluation of my medical condition than any available standard therapy, given my history of breast cancer and an extended family history of cancer. The reviewers were board-certified physicians with specialized expertise in genetics and treating my condition. The grounds for this determination were that the treatment was considered experimental/investigational. | The independent medical review found that the myRisk hereditary cancer genetic testing was likely to be more beneficial for evaluation of my medical condition than any available standard therapy, given my history of breast cancer and an extended family history of cancer. The reviewers were board-certified physicians with specialized expertise in genetics and treating my condition. The grounds for this determination were that the treatment was considered 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.
The internal medical review found that the independent review findings regarding the benefits of gene expression profiling (Oncotype DX prostate cancer assay) were not based on the statutory criteria for coverage. The review found that the Health Plan's decision to deny the enrollee's request for this service was not consistent with the NCCI maneuver code of 89603 that covers gene expression profiling for patients with low risk prostate cancer. The review further found that there is no evidence that the services at issue were experimental or investigational, as claimed by the Health Plan.
All three reviewers agree that gene expression profiling is a widely accepted and proven method for evaluating prostate cancer tumors and predicting disease outcomes. The review also noted that the NCCI maneuver code covers the use of gene expression profiling in low risk prostate cancer patients, and that the current American Urological Association guidelines recommend that patients with intermediate risk prostate cancer are candidates for active surveillance and gene expression profiling. The reviewers also cited an ongoing clinical trial (COST7266) that is currently recruiting patients with intermediate risk prostate cancer who are formally recommended for surveillance to undergo gene expression profiling and gene panel testing.
Therefore, the Health Plan's decision to deny the enrollees request for gene expression profiling is not supported by the statutory criteria, medical evidence, or clinical practice standards. The review highly recommends that the review findings be taken into account when making future decisions regarding coverage and reimbursement for this service.[/INST] | The treatment was not considered medically necessary as it was considered to be experimental/investigational. The review panel deemed that the utilization of such a service would not result in a better clinical outcome than the other available standard therapies. The Health Plan has maintained its decision to deny the request for reimbursement for any gene expression profiling (Oncotype DX prostate cancer assay) services, which were deemed to be unnecessary and not a demonstration of medical necessity. | The treatment was not considered medically necessary as it was considered to be experimental/investigational. The review panel deemed that the utilization of such a service would not result in a better clinical outcome than the other available standard therapies. The Health Plan has maintained its decision to deny the request for reimbursement for any gene expression profiling (Oncotype DX prostate cancer assay) services, which were deemed to be unnecessary and not a demonstration of medical necessity. |
[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 found that the independent review findings regarding the benefits of gene expression profiling (Oncotype DX prostate cancer assay) were not based on the statutory criteria for coverage. The review found that the Health Plan's decision to deny the enrollee's request for this service was not consistent with the NCCI maneuver code of 89603 that covers gene expression profiling for patients with low risk prostate cancer. The review further found that there is no evidence that the services at issue were experimental or investigational, as claimed by the Health Plan.
All three reviewers agree that gene expression profiling is a widely accepted and proven method for evaluating prostate cancer tumors and predicting disease outcomes. The review also noted that the NCCI maneuver code covers the use of gene expression profiling in low risk prostate cancer patients, and that the current American Urological Association guidelines recommend that patients with intermediate risk prostate cancer are candidates for active surveillance and gene expression profiling. The reviewers also cited an ongoing clinical trial (COST7266) that is currently recruiting patients with intermediate risk prostate cancer who are formally recommended for surveillance to undergo gene expression profiling and gene panel testing.
Therefore, the Health Plan's decision to deny the enrollees request for gene expression profiling is not supported by the statutory criteria, medical evidence, or clinical practice standards. The review highly recommends that the review findings be taken into account when making future decisions regarding coverage and reimbursement for this service.[/INST] | Dear Health Plan Administrator,
I am writing to appeal the denial of my recent request for reimbursement for gene expression profiling (Oncotype DX prostate cancer assay) for the evaluation of my prostate cancer. I believe that this testing is necessary to better understand my medical condition and to guide the course of my treatment.
As you may be aware, there are currently three major approaches to the management of localized prostate cancer. These include surgery, various forms of radiation therapy, or active surveillance. The recommendations for these options are based on risk stratification, which estimates the risk for the future development of progressive cancer. Various features of an individual's cancer, such as the pathologic details and PSA, are taken into consideration during this assessment.
In my case, my cancer is low to intermediate risk. If I did not have a Gleason 3+4 score, I would be considered low risk. Even if I were placed in the intermediate risk category, I would fall into a sub-group (favorable intermediate risk). The current recommendation for this category is active surveillance. However, I am seeking a further refinement of these prognostics through the use of gene panels, such as the Oncotype DX prostate cancer assay. This is a 17 gene panel that is capable of predicting recurrence after treatment for prostate cancer.
Evidence suggests that the use of gene expression profiling can identify treatment options for some Is who appear to have surgery | Dear Health Plan Administrator,
I am writing to appeal the denial of my recent request for reimbursement for gene expression profiling (Oncotype DX prostate cancer assay) for the evaluation of my prostate cancer. I believe that this testing is necessary to better understand my medical condition and to guide the course of my treatment.
As you may be aware, there are currently three major approaches to the management of localized prostate cancer. These include surgery, various forms of radiation therapy, or active surveillance. The recommendations for these options are based on risk stratification, which estimates the risk for the future development of progressive cancer. Various features of an individual's cancer, such as the pathologic details and PSA, are taken into consideration during this assessment.
In my case, my cancer is low to intermediate risk. If I did not have a Gleason 3+4 score, I would be considered low risk. Even if I were placed in the intermediate risk category, I would fall into a sub-group (favorable intermediate risk). The current recommendation for this category is active surveillance. However, I am seeking a further refinement of these prognostics through the use of gene panels, such as the Oncotype DX prostate cancer assay. This is a 17 gene panel that is capable of predicting recurrence after treatment for prostate cancer.
Evidence suggests that the use of gene expression profiling can identify treatment options for some Is who appear to have surgery |
[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 review findings, the physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. When feasible, community intervention settings offer optimization of treatment gains. Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions and substance dependence is a challenging endeavor. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.
This patient's records indicate that residential treatment was recommended by the treating providers who best knew the patient and the family system. However, due to significant affective symptomatologies and persistent suicidal ideation, a sedating antidepressant medication was added. A therapeutic family pass, which represents a tangible step in the discharge process, was denied two days later due to fear of self-harm. Nursing notes reported that the patient was isolating, needy, and tearful. However, the patient subsequently improved as evidenced by descriptive terms of positive day, uses leadership skills, and patient is skillful with minimal coaching. The provider's note on a day at issue was suggestive of medication adherence with good tolerability and efficacy coupled with the ability to use skills and refrain from engaging in self-harming behaviors. Furthermore, suicidal ideation was not endorsed in the mental status examination.
Consistent with the American Psychiatric Association (APA) guidelines, discharge on the date at issue would have been consistent with good medical practice. All told, the services provided for the dates at issue are supported as medically necessary for treatment of the patient's medical condition. The denial is grounds for Medical Necessity.[/INST] | Dear [Insurance Plan],
I am writing on behalf of I and her family to request coverage for residential treatment, psychiatric, and adolescent treatment level of care services provided from [date] and forward for treatment of her medical condition, which I describe as significant affective symptomatologies and persistent suicidal ideation leading to pathological self-defenses and negative schemas.
The independent medical review findings indicate that the physician reviewer found that modern psychiatric practice aims to place Is in the least restrictive treatment setting, and that determination of the appropriate level of care for adolescent Is with psychiatric conditions and substance dependence is a challenging endeavor. My records indicate that the treating providers advised residential treatment, which was denied to prevent self-harm despite successful medication management and improvement in my condition.
I understand that discharge on the date at issue would have been consistent with good medical practice as suggested by the American Psychiatric Association (APA) guidelines, and I urge you to approve coverage for the medical services provided for this I.
I appreciate your careful consideration of this matter, and hope for a prompt and positive response.
Sincerely,
[Your Name] | Dear [Insurance Plan],
I am writing on behalf of I and her family to request coverage for residential treatment, psychiatric, and adolescent treatment level of care services provided from [date] and forward for treatment of her medical condition, which I describe as significant affective symptomatologies and persistent suicidal ideation leading to pathological self-defenses and negative schemas.
The independent medical review findings indicate that the physician reviewer found that modern psychiatric practice aims to place Is in the least restrictive treatment setting, and that determination of the appropriate level of care for adolescent Is with psychiatric conditions and substance dependence is a challenging endeavor. My records indicate that the treating providers advised residential treatment, which was denied to prevent self-harm despite successful medication management and improvement in my condition.
I understand that discharge on the date at issue would have been consistent with good medical practice as suggested by the American Psychiatric Association (APA) guidelines, and I urge you to approve coverage for the medical services provided for this I.
I appreciate your careful consideration of this matter, and hope for a prompt and positive response.
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.
Based on the internal review findings, the physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. When feasible, community intervention settings offer optimization of treatment gains. Due to multiple factors and unique considerations, determination of the appropriate level of care for adolescent patients with psychiatric conditions and substance dependence is a challenging endeavor. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.
This patient's records indicate that residential treatment was recommended by the treating providers who best knew the patient and the family system. However, due to significant affective symptomatologies and persistent suicidal ideation, a sedating antidepressant medication was added. A therapeutic family pass, which represents a tangible step in the discharge process, was denied two days later due to fear of self-harm. Nursing notes reported that the patient was isolating, needy, and tearful. However, the patient subsequently improved as evidenced by descriptive terms of positive day, uses leadership skills, and patient is skillful with minimal coaching. The provider's note on a day at issue was suggestive of medication adherence with good tolerability and efficacy coupled with the ability to use skills and refrain from engaging in self-harming behaviors. Furthermore, suicidal ideation was not endorsed in the mental status examination.
Consistent with the American Psychiatric Association (APA) guidelines, discharge on the date at issue would have been consistent with good medical practice. All told, the services provided for the dates at issue are supported as medically necessary for treatment of the patient's medical condition. The denial is grounds for Medical Necessity.[/INST] | The treatment is considered medically necessary because it was recommended by the treating providers, who best knew the I and the family system, and it was consistent with modern psychiatric practice to place Is in the least restrictive treatment setting when feasible. Ihad significant affective symptomatologies, persistent suicidal ideation, and was isolated and tearful. However, the I improved as evidenced by positive descriptive terms, leadership skills, and minimal coaching. Iwas also found to have medication adherence with good tolerability and efficacy, and suicidal ideation was not endorsed in the mental status examination. All of these factors were consistent with the American Psychiatric Association (APA) guidelines and supported the medical necessity of the treatment for the dates at issue. | The treatment is considered medically necessary because it was recommended by the treating providers, who best knew the I and the family system, and it was consistent with modern psychiatric practice to place Is in the least restrictive treatment setting when feasible. Ihad significant affective symptomatologies, persistent suicidal ideation, and was isolated and tearful. However, the I improved as evidenced by positive descriptive terms, leadership skills, and minimal coaching. Iwas also found to have medication adherence with good tolerability and efficacy, and suicidal ideation was not endorsed in the mental status examination. All of these factors were consistent with the American Psychiatric Association (APA) guidelines and supported the medical necessity of the treatment for the dates at issue. |
[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.
Medical review findings:
An internal review of a 54-year-old male enrollee's request for sacroiliac joint arthrography and injections for treatment of sacroiliac joint pain show that the medical literature suggests mixed results in the use of these interventions for the management of chronic low back pain. Sacroiliac joint injections may have a diagnosticcomponent. However, their effectiveness in selected cases may provide significant relief from intractable pain caused by joint dysfunction. The patient has a documented improvement from the injections and the review was conducted based on Experimental/Investigational grounds.[/INST] | The treatment of sacroiliac joint arthrography and injections for treatment of sacroiliac joint pain was found to have mixed reviews in the medical literature and a diagnostic component. Evidence suggests that the treatment can be helpful in managing intractable pain due to joint dysfunction. Ihad documented improvement from these injections. The grounds for the treatment being considered medically necessary were experimental/investigational. | The treatment of sacroiliac joint arthrography and injections for treatment of sacroiliac joint pain was found to have mixed reviews in the medical literature and a diagnostic component. Evidence suggests that the treatment can be helpful in managing intractable pain due to joint dysfunction. Ihad documented improvement from these injections. The grounds for the treatment being considered medically necessary were 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.
Medical review findings:
An internal review of a 54-year-old male enrollee's request for sacroiliac joint arthrography and injections for treatment of sacroiliac joint pain show that the medical literature suggests mixed results in the use of these interventions for the management of chronic low back pain. Sacroiliac joint injections may have a diagnosticcomponent. However, their effectiveness in selected cases may provide significant relief from intractable pain caused by joint dysfunction. The patient has a documented improvement from the injections and the review was conducted based on Experimental/Investigational grounds.[/INST] | Dear Sir/Madam,
Ihe I, who is a 54-year-old male enrollee requesting sacroiliac joint arthrography and injections for the treatment of sacroiliac joint pain.
According to two physician reviewers who reviewed the medical literature, the use of sacroiliac joint injections for the management of chronic low back pain is a mixed topic. While these injections may have a diagnostic component, they do not have sufficient evidence to establish their effectiveness or safety in all cases.
However, taking into account my experiencing documented improvement from the treatment, s have concluded that the sacroiliac joint joints may be beneficial in some cases, particularly in Is with intractable pain due to joint dysfunction.
Therefore, we request a review of my case to consider the use of sacroiliac joint arthrography and injections as an experimental/investigational treatment option for managing their chronic low back pain.
Thank you for your consideration.
Sincerely,
[Your Name] | Dear Sir/Madam,
Ihe I, who is a 54-year-old male enrollee requesting sacroiliac joint arthrography and injections for the treatment of sacroiliac joint pain.
According to two physician reviewers who reviewed the medical literature, the use of sacroiliac joint injections for the management of chronic low back pain is a mixed topic. While these injections may have a diagnostic component, they do not have sufficient evidence to establish their effectiveness or safety in all cases.
However, taking into account my experiencing documented improvement from the treatment, s have concluded that the sacroiliac joint joints may be beneficial in some cases, particularly in Is with intractable pain due to joint dysfunction.
Therefore, we request a review of my case to consider the use of sacroiliac joint arthrography and injections as an experimental/investigational treatment option for managing their chronic low back pain.
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.
Form Letter: Insurance Denial for Residential Treatment Center (RTC) Services
Dear [Recipient],
We regret to inform you that the review of the patient's claim for residential treatment center (RTC) services has been denied. The review was conducted by an independent medical review board who focused on six dimensions to determine the appropriate level of care.
After careful consideration of all documentation provided, the RTC level of care services were deemed medically necessary for the treatment of the patient's medical condition. However, due to the complexity of the patient's medical condition and the level of care required for treatment, we are unable to authorize the requested RTC services at this time.
The review board isction reviewed the patient's case thoroughly, and based on the information provided, the patient meets Level 3.5 ASAM clinically managed high-intensity residential services criteria. The ASAM criteria includes six dimensions:
1. Intoxication and withdrawal potential
2. Biomedical conditions
3. Emotional, behavioral, and cognitive conditions
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery environment.
It is our recommendation that the patient continues with their current treatment plan, and we encourage them to consider alternative forms of treatment that are covered by their insurance plan.
If you have any questions or concerns, please do not hesitate to contact us at [insert contact information].
Sincerely,
[Your Name][/INST] | Dear Health Plan Denial Review,
Ihe I who has requested reimbursement for residential treatment center (RTC) services. I understand that the independent medical review findings have evaluated my situation and determined that the I met Level 3.5 criteria for clinically managed high-intensity residential services. The review focused on six dimensions to determine the appropriate level of care: intoxication and withdrawal potential, biomedical conditions, emotional, behavioral and cognitive conditions, readiness to change, relapse, continued use, or continued problem potential, and recovery environment. Based on the documentation provided, determined that the services at issue were medically necessary for treatment of my medical condition.
Therefore, I request that the Health Plan denial be overturned in accordance with the medical necessity criteria.
Sincerely,
[Your Name] | Dear Health Plan Denial Review,
Ihe I who has requested reimbursement for residential treatment center (RTC) services. I understand that the independent medical review findings have evaluated my situation and determined that the I met Level 3.5 criteria for clinically managed high-intensity residential services. The review focused on six dimensions to determine the appropriate level of care: intoxication and withdrawal potential, biomedical conditions, emotional, behavioral and cognitive conditions, readiness to change, relapse, continued use, or continued problem potential, and recovery environment. Based on the documentation provided, determined that the services at issue were medically necessary for treatment of my medical condition.
Therefore, I request that the Health Plan denial be overturned in accordance with the medical necessity criteria.
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.
Form Letter: Insurance Denial for Residential Treatment Center (RTC) Services
Dear [Recipient],
We regret to inform you that the review of the patient's claim for residential treatment center (RTC) services has been denied. The review was conducted by an independent medical review board who focused on six dimensions to determine the appropriate level of care.
After careful consideration of all documentation provided, the RTC level of care services were deemed medically necessary for the treatment of the patient's medical condition. However, due to the complexity of the patient's medical condition and the level of care required for treatment, we are unable to authorize the requested RTC services at this time.
The review board isction reviewed the patient's case thoroughly, and based on the information provided, the patient meets Level 3.5 ASAM clinically managed high-intensity residential services criteria. The ASAM criteria includes six dimensions:
1. Intoxication and withdrawal potential
2. Biomedical conditions
3. Emotional, behavioral, and cognitive conditions
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery environment.
It is our recommendation that the patient continues with their current treatment plan, and we encourage them to consider alternative forms of treatment that are covered by their insurance plan.
If you have any questions or concerns, please do not hesitate to contact us at [insert contact information].
Sincerely,
[Your Name][/INST] | Type: Fact-Finding PPM Finding: RTC Services for Patient with Level 3.5 Criteria.
Why: Patient with clinically managed high-intensity residential services per American Society of Addiction Medicine (ASAM) criteria. Six dimensions are used to determine appropriate level of care, including: (1) intoxication and withdrawal potential, (2) biomedical conditions, (3) emotional, behavioral, cognitive conditions, (4) readiness to change, (5) relapse, continued use, or continued problem potential, and (6) recovery environment.
Ruling: Services at issue were medically necessary for treatment of I's medical condition.
Credentials: Reviewer board certified in psychiatry with addiction medicine expertise, with recent or current clinical experience treating those with similar medical condition.
Grounds: Medical Necessity. | Type: Fact-Finding PPM Finding: RTC Services for Patient with Level 3.5 Criteria.
Why: Patient with clinically managed high-intensity residential services per American Society of Addiction Medicine (ASAM) criteria. Six dimensions are used to determine appropriate level of care, including: (1) intoxication and withdrawal potential, (2) biomedical conditions, (3) emotional, behavioral, cognitive conditions, (4) readiness to change, (5) relapse, continued use, or continued problem potential, and (6) recovery environment.
Ruling: Services at issue were medically necessary for treatment of I's medical condition.
Credentials: Reviewer board certified in psychiatry with addiction medicine expertise, with recent or current clinical experience treating those with similar medical condition.
Grounds: Medical Necessity. |
[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 a thorough internal review of the current medical literature, we have determined that viscosupplementation for knee pain is not consistently effective and its success varies depending on the individual patient. Several systematic reviews and randomized controlled trials have attempted to determine the effectiveness of viscosupplementation with different agents, including corticosteroids and platelet-rich plasma. However, the current evidence is limited, and the American Academy of Orthopedic Surgeons does not have conclusive evidence to support the use of viscosupplementation.
Given this information, we respectfully inform you that viscosupplementation for the enrollee's left knee is not considered medically necessary as there are limited effective options available. We encourage further evaluation of the enrollee's condition and a thorough exploration of alternative treatment options before proceeding with any further procedures.
Please note that this decision is based solely on the medical necessity criteria as outlined in the policy and may not be deemed appropriate in all circumstances. Additionally, the reviewer's qualifications are restricted to their clinical experience treating those with a similar medical condition.[/INST] | The requested Supartz injection series in the left knee for an individual with osteoarthritis was deemed medically necessary due to the individual's history of lasting benefit from prior injections, and limitations on alternative treatments. The reviewer, who is an expert in the treatment of the condition and has clinical experience treating Is with a similar medical condition, concluded that the requested service was necessary to treat my medical condition. The reviewer's bases for the decision were the mixed results of current medical literature and the limited evidence from previous studies that suggests viscosupplementation may not be effective for everyone. As such, concluded that the requested service was medically necessary and recommended its coverage by the health plans. | The requested Supartz injection series in the left knee for an individual with osteoarthritis was deemed medically necessary due to the individual's history of lasting benefit from prior injections, and limitations on alternative treatments. The reviewer, who is an expert in the treatment of the condition and has clinical experience treating Is with a similar medical condition, concluded that the requested service was necessary to treat my medical condition. The reviewer's bases for the decision were the mixed results of current medical literature and the limited evidence from previous studies that suggests viscosupplementation may not be effective for everyone. As such, concluded that the requested service was medically necessary and recommended its coverage by the health plans. |
[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 a thorough internal review of the current medical literature, we have determined that viscosupplementation for knee pain is not consistently effective and its success varies depending on the individual patient. Several systematic reviews and randomized controlled trials have attempted to determine the effectiveness of viscosupplementation with different agents, including corticosteroids and platelet-rich plasma. However, the current evidence is limited, and the American Academy of Orthopedic Surgeons does not have conclusive evidence to support the use of viscosupplementation.
Given this information, we respectfully inform you that viscosupplementation for the enrollee's left knee is not considered medically necessary as there are limited effective options available. We encourage further evaluation of the enrollee's condition and a thorough exploration of alternative treatment options before proceeding with any further procedures.
Please note that this decision is based solely on the medical necessity criteria as outlined in the policy and may not be deemed appropriate in all circumstances. Additionally, the reviewer's qualifications are restricted to their clinical experience treating those with a similar medical condition.[/INST] | Dear Health Plans,
I am writing to appeal the denial of my request for Supartz injection series for the treatment of my left knee condition. I believe that the requested treatment is medically necessary for my condition and I have provided all necessary documentation to support my claim.
I understand that the independent medical review found the evidence for viscosupplementation to be mixed, but I believe that the current evidence is sufficient to recommend this treatment for my case. I have tried and failed other conservative treatments, and Surgery is not an option. I have found that Supartz injections have had lasting benefits for Is with similar medical conditions.
Additionally, I understand that the anonymous reviewer is not the person who has personally treated me and does not have the detailed knowledge and expertise about my specific condition that a treating physician would possess. I am concerned that made their determination without having the ability to examine my individual circumstances and understand the limitations and benefits of this treatment for my unique case.
I have followed all necessary steps to obtain medical care for my condition, and I request that you reconsider the denial of my request for Supartz injection series in light of the evidence and my individual circumstances. I hope that you will grant me this access to the treatment that I desperately need to manage my pain and improve my quality of life.
Thank you for your attention to this matter. | Dear Health Plans,
I am writing to appeal the denial of my request for Supartz injection series for the treatment of my left knee condition. I believe that the requested treatment is medically necessary for my condition and I have provided all necessary documentation to support my claim.
I understand that the independent medical review found the evidence for viscosupplementation to be mixed, but I believe that the current evidence is sufficient to recommend this treatment for my case. I have tried and failed other conservative treatments, and Surgery is not an option. I have found that Supartz injections have had lasting benefits for Is with similar medical conditions.
Additionally, I understand that the anonymous reviewer is not the person who has personally treated me and does not have the detailed knowledge and expertise about my specific condition that a treating physician would possess. I am concerned that made their determination without having the ability to examine my individual circumstances and understand the limitations and benefits of this treatment for my unique case.
I have followed all necessary steps to obtain medical care for my condition, and I request that you reconsider the denial of my request for Supartz injection series in light of the evidence and my individual circumstances. I hope that you will grant me this access to the treatment that I desperately need to manage my pain and improve my quality of life.
Thank you for your attention to this matter. |
[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 independent assure assessment of the patient's case summary and the nature of the statutory criteria, it has been determined that the requested services are not medically necessary to treat the patient's medical condition as defined in Health and Safety code section 1374(a)(3)(A).
According to the Centers for Medicare and Medicaid Services (CMS), a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider, Medicare requires more clinically appropriate inpatient hospitalization.
The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for 14 days for inpatient hospitalization.
Based on the patient's scores and the documentation provided, the requested residential treatment center services are not considered medically necessary to treat the patient's condition as defined in Health and Safety code section 1374(a)(3)(A). Instead, the patient will be eligible for 14 days of inpatient hospitalization as determined based on the patient's scores and documentation.
Please note that this letter is based on the assumption that we have all necessary information, including the patient's recent medical evaluations, to determine the medical necessity of the requested treatment. If any additional information or documentation is needed to make a final determination, we will request it as soon as possible.[/INST] | Dear Authorization and Coverage Team,
I am writing on behalf of [I name] who is requesting authorization and coverage for 30 days of residential treatment center services. As per Health and Safety code section 1374(a)(3)(A), as well as the code set forth in this case, the I has a medical condition that requires treatment. Ihas been actively seeking treatment, and it is the recommendation of the independent medical reviewer that 30 days of residential treatment center services are medically necessary to address my medical condition.
The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score Is on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive, and psychiatric comorbidity; (4) recovery environment; (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the I met the criteria for 30 days of residential treatment center services.
The records indicate that the I has a moderate risk for harm, and their functional status is also at a moderate level due to their inability to work, relationship issues, and difficulty fulfilling responsibilities. It is, therefore, in accordance with generally accepted standards of mental health and substance use disorder care and clinically appropriate in terms of type, frequency, extent, site, and duration to recommend that 30 days of residential treatment center services are medically necessary to treat my medical condition.
I kindly ask that you favorably consider our request for authorization and coverage of the recommended 30 days of residential treatment center services.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Dear Authorization and Coverage Team,
I am writing on behalf of [I name] who is requesting authorization and coverage for 30 days of residential treatment center services. As per Health and Safety code section 1374(a)(3)(A), as well as the code set forth in this case, the I has a medical condition that requires treatment. Ihas been actively seeking treatment, and it is the recommendation of the independent medical reviewer that 30 days of residential treatment center services are medically necessary to address my medical condition.
The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score Is on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive, and psychiatric comorbidity; (4) recovery environment; (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the I met the criteria for 30 days of residential treatment center services.
The records indicate that the I has a moderate risk for harm, and their functional status is also at a moderate level due to their inability to work, relationship issues, and difficulty fulfilling responsibilities. It is, therefore, in accordance with generally accepted standards of mental health and substance use disorder care and clinically appropriate in terms of type, frequency, extent, site, and duration to recommend that 30 days of residential treatment center services are medically necessary to treat my medical condition.
I kindly ask that you favorably consider our request for authorization and coverage of the recommended 30 days of residential treatment center services.
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.
Based on the independent assure assessment of the patient's case summary and the nature of the statutory criteria, it has been determined that the requested services are not medically necessary to treat the patient's medical condition as defined in Health and Safety code section 1374(a)(3)(A).
According to the Centers for Medicare and Medicaid Services (CMS), a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider, Medicare requires more clinically appropriate inpatient hospitalization.
The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for 14 days for inpatient hospitalization.
Based on the patient's scores and the documentation provided, the requested residential treatment center services are not considered medically necessary to treat the patient's condition as defined in Health and Safety code section 1374(a)(3)(A). Instead, the patient will be eligible for 14 days of inpatient hospitalization as determined based on the patient's scores and documentation.
Please note that this letter is based on the assumption that we have all necessary information, including the patient's recent medical evaluations, to determine the medical necessity of the requested treatment. If any additional information or documentation is needed to make a final determination, we will request it as soon as possible.[/INST] | The treatment considered medically necessary was 30 days of residential treatment center services based on my score of 3 on the risk of harm dimension and 3 on the functional status dimension using the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS). My passive suicidal ideation without intent or plan and inability to work and fulfill responsibilities for several months indicated a moderate risk of harm and decreased functional status, making residential treatment center services clinically appropriate for my mental health condition. | The treatment considered medically necessary was 30 days of residential treatment center services based on my score of 3 on the risk of harm dimension and 3 on the functional status dimension using the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS). My passive suicidal ideation without intent or plan and inability to work and fulfill responsibilities for several months indicated a moderate risk of harm and decreased functional status, making residential treatment center services clinically appropriate for my mental health 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.
To be concise, I can rephrase the information provided in the original response into the following:
The independent medical review findings indicate that genetic testing, using a multiplexed approach like FoundationOne Heme, is likely to be more beneficial for the evaluation of the patient's medical condition than any available standard therapy. The reviewers, who are board certified in internal medicine with specialty certification in medical oncology, are experts in treating the patient's medical condition and have relevant clinical experience. Therefore, the health plan's denial of the service should stand., as the [/INST] | On behalf of [Patient's Name], I am writing an appeal against the denial of request for gene testing evaluation by our health plan. The requested testing is essential for the evaluation of the I who has a history of lymphoma and is suspicious of Follicular helper like T cell lymphoma. However, the physician reviewers have found that this new entity is rare in individuals and there is a lack of standard therapies for its treatment. Genetic testing, such as the FoundationOne Heme, is likely to be more beneficial for the evaluation of my medical condition compared to any available treatment.
During the review process, the independent medical review board consisted of three physician reviewers who were board certified in internal medicine with sub-specialty certification in medical oncology and had extensive knowledge and experience in treating similar medical conditions. The findings of the review board concluded that the services at issue were likely to have been more beneficial for evaluation of my medical condition than any available standard therapy.
Therefore, I am requesting that the denial of the requested evaluation be overturned, and the I be granted access to the gene testing evaluation. I am confident that this testing will assist my medical team in identifying the most appropriate treatment plan for their condition. | On behalf of [Patient's Name], I am writing an appeal against the denial of request for gene testing evaluation by our health plan. The requested testing is essential for the evaluation of the I who has a history of lymphoma and is suspicious of Follicular helper like T cell lymphoma. However, the physician reviewers have found that this new entity is rare in individuals and there is a lack of standard therapies for its treatment. Genetic testing, such as the FoundationOne Heme, is likely to be more beneficial for the evaluation of my medical condition compared to any available treatment.
During the review process, the independent medical review board consisted of three physician reviewers who were board certified in internal medicine with sub-specialty certification in medical oncology and had extensive knowledge and experience in treating similar medical conditions. The findings of the review board concluded that the services at issue were likely to have been more beneficial for evaluation of my medical condition than any available standard therapy.
Therefore, I am requesting that the denial of the requested evaluation be overturned, and the I be granted access to the gene testing evaluation. I am confident that this testing will assist my medical team in identifying the most appropriate treatment plan for their 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.
To be concise, I can rephrase the information provided in the original response into the following:
The independent medical review findings indicate that genetic testing, using a multiplexed approach like FoundationOne Heme, is likely to be more beneficial for the evaluation of the patient's medical condition than any available standard therapy. The reviewers, who are board certified in internal medicine with specialty certification in medical oncology, are experts in treating the patient's medical condition and have relevant clinical experience. Therefore, the health plan's denial of the service should stand., as the [/INST] | 1. The independent medical review findings are for a request for reimbursement for gene testing to evaluate a I with a history of lymphoma.
2. The physician reviewers found that Follicular helper-like T cell lymphoma is a rare and newly described entity mostly seen in elderly males with no standard therapies yet defined. They also mentioned that the precise events driving angioimmunoblastic T cell lymphoma (AITL) oncogenesis are not fully understood but several molecular anomalies have been described in AITL.
3. Multiplexed genotype testing, such as with FoundationOne Heme, can test an entire panel of genotypes of interest at a single time from a single tissue sample, making it the most tissue efficient approach, particularly when dealing with small tumor samples.
4. Two of three reviewers determined that the services at issue were likely to have been more beneficial for evaluation of my medical condition than any available standard therapy.
5. The physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and have active clinical experience treating Is with the same or similar medical condition.
6. The treatment is considered medically necessary because it would be more beneficial than any available standard therapy for my medical condition. | 1. The independent medical review findings are for a request for reimbursement for gene testing to evaluate a I with a history of lymphoma.
2. The physician reviewers found that Follicular helper-like T cell lymphoma is a rare and newly described entity mostly seen in elderly males with no standard therapies yet defined. They also mentioned that the precise events driving angioimmunoblastic T cell lymphoma (AITL) oncogenesis are not fully understood but several molecular anomalies have been described in AITL.
3. Multiplexed genotype testing, such as with FoundationOne Heme, can test an entire panel of genotypes of interest at a single time from a single tissue sample, making it the most tissue efficient approach, particularly when dealing with small tumor samples.
4. Two of three reviewers determined that the services at issue were likely to have been more beneficial for evaluation of my medical condition than any available standard therapy.
5. The physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and have active clinical experience treating Is with the same or similar medical condition.
6. The treatment is considered medically necessary because it would be more beneficial than any available standard therapy for 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.
Thank you for providing more context. Based on the information provided, here is an example of an insurance denial:
Dear [Enrollee's Name],
We are writing to inform you that your request for speech therapy for your two-year-old male enrollee has been denied. Our review of the request found that speech and language development is an important indicator of a child's overall development and cognitive ability, and is related to school success. However, we have also found that speech and language delay may be a risk factor for long-term problems concerning literacy, socialization, behavior, and school attainment if it persists into primary school.
The medical evidence supports the requested speech therapy in this clinical scenario, as severe expressive language delay can significantly impair a child's ability to communicate effectively. However, since we have determined that the requested speech therapy is not medically necessary for the treatment of this condition, we must deny the request at this time.
We hope that you will consider alternative treatment options that may be more appropriate for your enrollee's needs. Please do not hesitate to contact us if you have any further questions or concerns.
Sincerely,
[Your Name][/INST] | The treatment of severe expressive language delay in a two-year-old male enrollee is considered medically necessary due to my significant impairment in communicating effectively, which is considered a useful indicator of overall development, cognitive ability and school success by experts. Children with speech and language difficulties may have long-term problems concerning literacy, socialization, behavior, and school attainment if their difficulties persist into primary school. The current medical evidence supports the requested speech therapy, which is indicated at a frequency of one day per week, one hour per session. | The treatment of severe expressive language delay in a two-year-old male enrollee is considered medically necessary due to my significant impairment in communicating effectively, which is considered a useful indicator of overall development, cognitive ability and school success by experts. Children with speech and language difficulties may have long-term problems concerning literacy, socialization, behavior, and school attainment if their difficulties persist into primary school. The current medical evidence supports the requested speech therapy, which is indicated at a frequency of one day per week, one hour per session. |
[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.
Thank you for providing more context. Based on the information provided, here is an example of an insurance denial:
Dear [Enrollee's Name],
We are writing to inform you that your request for speech therapy for your two-year-old male enrollee has been denied. Our review of the request found that speech and language development is an important indicator of a child's overall development and cognitive ability, and is related to school success. However, we have also found that speech and language delay may be a risk factor for long-term problems concerning literacy, socialization, behavior, and school attainment if it persists into primary school.
The medical evidence supports the requested speech therapy in this clinical scenario, as severe expressive language delay can significantly impair a child's ability to communicate effectively. However, since we have determined that the requested speech therapy is not medically necessary for the treatment of this condition, we must deny the request at this time.
We hope that you will consider alternative treatment options that may be more appropriate for your enrollee's needs. Please do not hesitate to contact us if you have any further questions or concerns.
Sincerely,
[Your Name][/INST] | Dear [Insurance Company],edical Review Committee,
Ihe parent of a two-year-old male enrollee who has requested speech therapy services. Iis currently experiencing severe expressive language delay which is significantly impairing his ability to communicate effectively.
According to numerous studies, speech and language development is a critical aspect of a child's overall development and cognitive ability, and is closely related to school success. Identifying children at risk for developmental delay or related problems at a young age can lead to intervention services and family assistance when the chances for improvement are at their highest.
Issues with speech and language development can have long-term consequences if left untreated. Approximately 6% of children have speech and language difficulties, and those whose difficulties persist into primary school may have ongoing issues with literacy, socialization, behavior, and school attainment.
Research by Bernhardt and Major has shown that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.
The current medical evidence supports the requested speech therapy in this clinical scenario as the I is exhibiting severe expressive language delay. Speech therapy, at a frequency of one day per week, one hour per session, is therefore medically indicated for the treatment of this I.
Sincerely,
[Your Name] | Dear [Insurance Company],edical Review Committee,
Ihe parent of a two-year-old male enrollee who has requested speech therapy services. Iis currently experiencing severe expressive language delay which is significantly impairing his ability to communicate effectively.
According to numerous studies, speech and language development is a critical aspect of a child's overall development and cognitive ability, and is closely related to school success. Identifying children at risk for developmental delay or related problems at a young age can lead to intervention services and family assistance when the chances for improvement are at their highest.
Issues with speech and language development can have long-term consequences if left untreated. Approximately 6% of children have speech and language difficulties, and those whose difficulties persist into primary school may have ongoing issues with literacy, socialization, behavior, and school attainment.
Research by Bernhardt and Major has shown that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.
The current medical evidence supports the requested speech therapy in this clinical scenario as the I is exhibiting severe expressive language delay. Speech therapy, at a frequency of one day per week, one hour per session, is therefore medically indicated for the treatment of this I.
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 Insurance Denial Letter:
Dear [Enrollee],
After reviewing the independent medical review findings, we have determined that the requested Botox injections are not covered under your health plan. Our medical necessity team has reviewed the American Headache Society (AHS) and the American Academy of Neurology (AAN) guidelines on the use of botulinum neurotoxin for brain disorders. Based on the patient's history of chronic migraines that did not respond to oral preventative medications, including Aimovig, Topamax, phenytoin, and sumatriptan, the patient is not an appropriate candidate for prophylactic treatment with botulinum toxin therapy.
Our reviewers are board certified in neurology and actively practicing in the field. They have extensive knowledge and clinical experience treating patients with chronic migraines. However, the evidence indicates that onabotulinumtoxinA is not an effective or a well-tolerated option for the prevention of chronic migraines, even for patients who have failed to respond to or are intolerant of commonly prescribed oral prophylactics.
We understand that this decision may be difficult for you to come to terms with, but we hope that you will continue to work closely with your healthcare provider to identify alternative treatments that may be more effective for your condition.
Sincerely,
[Your Name]
The Health Plan[/INST] | Thank you for your medical review. We understand and appreciate your expertise in the treatment of my medical condition. Based on my medical history and the recent medical review, we are writing to appeal the denial of coverage for Botox injections as a medically necessary treatment for my chronic migraines.
Ihas a history of chronic migraines that did not respond to oral preventative medications, including Aimovig, Topamax, phenytoin, and sumatriptan, despite their recommendation and use of them. The American Headache Society (AHS) recommends preventive treatment for chronic migraines when attacks significantly interfere with a I's daily routine, and there are four or more attacks per month. In addition, the American Academy of Neurology (AAN) updated its 2008 guidelines in 2016 and recommended botulinum toxin A for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months.
According to the AHS statement, AAN guideline, and a 2018 review of the current evidence of onabotulinumtoxinA in stopping chronic migraines, onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines. It is particularly useful for Is who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics.
Considering my medical history, medical review, and available evidence, we strongly believe that Botox injections are medically necessary for the treatment of my chronic migraines. We kindly request that you reconsider the denial of coverage for this treatment and ensure that our I can receive the necessary care to treat their medical condition.
We appreciate your time and consideration. If you have any further questions or concerns, please do not hesitate to contact us. | Thank you for your medical review. We understand and appreciate your expertise in the treatment of my medical condition. Based on my medical history and the recent medical review, we are writing to appeal the denial of coverage for Botox injections as a medically necessary treatment for my chronic migraines.
Ihas a history of chronic migraines that did not respond to oral preventative medications, including Aimovig, Topamax, phenytoin, and sumatriptan, despite their recommendation and use of them. The American Headache Society (AHS) recommends preventive treatment for chronic migraines when attacks significantly interfere with a I's daily routine, and there are four or more attacks per month. In addition, the American Academy of Neurology (AAN) updated its 2008 guidelines in 2016 and recommended botulinum toxin A for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months.
According to the AHS statement, AAN guideline, and a 2018 review of the current evidence of onabotulinumtoxinA in stopping chronic migraines, onabotulinumtoxinA is an effective and generally well-tolerated option for the prevention of chronic migraines. It is particularly useful for Is who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics.
Considering my medical history, medical review, and available evidence, we strongly believe that Botox injections are medically necessary for the treatment of my chronic migraines. We kindly request that you reconsider the denial of coverage for this treatment and ensure that our I can receive the necessary care to treat their medical condition.
We appreciate your time and consideration. If you have any further questions or concerns, please do not hesitate to contact us. |
[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 Insurance Denial Letter:
Dear [Enrollee],
After reviewing the independent medical review findings, we have determined that the requested Botox injections are not covered under your health plan. Our medical necessity team has reviewed the American Headache Society (AHS) and the American Academy of Neurology (AAN) guidelines on the use of botulinum neurotoxin for brain disorders. Based on the patient's history of chronic migraines that did not respond to oral preventative medications, including Aimovig, Topamax, phenytoin, and sumatriptan, the patient is not an appropriate candidate for prophylactic treatment with botulinum toxin therapy.
Our reviewers are board certified in neurology and actively practicing in the field. They have extensive knowledge and clinical experience treating patients with chronic migraines. However, the evidence indicates that onabotulinumtoxinA is not an effective or a well-tolerated option for the prevention of chronic migraines, even for patients who have failed to respond to or are intolerant of commonly prescribed oral prophylactics.
We understand that this decision may be difficult for you to come to terms with, but we hope that you will continue to work closely with your healthcare provider to identify alternative treatments that may be more effective for your condition.
Sincerely,
[Your Name]
The Health Plan[/INST] | The treatment is considered medically necessary because the I has a history of chronic migraines that did not respond to oral preventative medications and is an appropriate candidate for prophylactic treatment with botulinum toxin therapy based on the American Headache Society (AHS) statement, American Academy of Neurology (AAN) guideline, and a study noted above. | The treatment is considered medically necessary because the I has a history of chronic migraines that did not respond to oral preventative medications and is an appropriate candidate for prophylactic treatment with botulinum toxin therapy based on the American Headache Society (AHS) statement, American Academy of Neurology (AAN) guideline, and a study noted above. |
[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.
Case Summary: An enrollee with breast cancer has requested suction assisted lipectomy of the trunk for the treatment of her medical condition. Internal medical review findings conclude that the services at issue are medically necessary for the treatment of this patient. Based on the patient's evaluation and review of the photographs, the appearance of the axillae is related to her treatment of breast cancer. The patient's condition constitutes an abnormal structure of the body. This abnormal structure of the body was a direct result of her treatment for breast cancer. The surgery was performed to create a normal appearance to the extent possible. The level of abnormality was significant and the planned procedure was in an attempt to approximate a more normal appearance. The liposuction would likely to have offered more than a minimal improvement in the patient's appearance. In sum, suction assisted lipectomy of the trunk was medically necessary and was reconstructive in nature. The reviewer is board certified in plastic surgery and actively practicing. The reviewer 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 the same or a similar medical condition. The reason for denial is Medical Necessity. Denial should stand.[/INST] | Dear Health Plan,
We are writing to appeal the denial of suction assisted lipectomy of the trunk for the treatment of our I's medical condition. The independent medical review findings have determined that the services at issue were medically necessary and reconstructive in nature for the treatment of our I's medical condition.
Our I has been diagnosed with breast cancer and has undergone treatment that has resulted in an abnormal structure of the body, particularly with the appearance of the axillae in the enclosed photographs. Our I's medical condition is an abnormal structure of the body that was directly related to her treatment for breast cancer.
The physician has found that the surgery performed was to create as normal an appearance as possible to the extent possible, acknowledging that there would be some degree of remaining abnormal structures. The liposuction would have offered more than minimal improvement to our I's appearance.
We agree with the physician's findings, and we believe that the denial of suction assisted lipectomy of the trunk is inappropriate in light of our I's medical condition and previous treatment. We kindly request that this denial be overturned and the appropriate coverage be reinstated for the I.
Thank you for your attention to this matter.
Sincerely,
[Your Name] | Dear Health Plan,
We are writing to appeal the denial of suction assisted lipectomy of the trunk for the treatment of our I's medical condition. The independent medical review findings have determined that the services at issue were medically necessary and reconstructive in nature for the treatment of our I's medical condition.
Our I has been diagnosed with breast cancer and has undergone treatment that has resulted in an abnormal structure of the body, particularly with the appearance of the axillae in the enclosed photographs. Our I's medical condition is an abnormal structure of the body that was directly related to her treatment for breast cancer.
The physician has found that the surgery performed was to create as normal an appearance as possible to the extent possible, acknowledging that there would be some degree of remaining abnormal structures. The liposuction would have offered more than minimal improvement to our I's appearance.
We agree with the physician's findings, and we believe that the denial of suction assisted lipectomy of the trunk is inappropriate in light of our I's medical condition and previous treatment. We kindly request that this denial be overturned and the appropriate coverage be reinstated for the I.
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 external board review found that a female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus genotype 1a. Based on clinical guidelines and published evidence, the requested treatment consisting of Harvoni for 12 weeks should be considered medically necessary in this patient's case.[/INST] | Dear Sir/Madam,
I am writing on behalf of [Patient Name], a female enrollee who is requesting Harvoni for 12 weeks of medical treatment for her hepatitis C virus genotype 1a.
After reviewing the independent medical review findings, we, as an advocate for the I, believe that the requested treatment should be considered medically necessary.
According to the most recent 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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to nonliver-related comorbid conditions. Given that [Patient Name] does not fit into any of these exclusion criteria, we believe that she is eligible for treatment.
Furthermore, Is who have failed treatment with peginterferon-based regimens are recommended to be re-treated with daily Harvoni for 12 weeks. Since [Patient Name] has failed previous treatment regimens, we believe that she would be a good candidate for this treatment.
Based on published evidence of safety and efficacy in the medical literature, and clinical guidelines, we support my request for Harvoni for 12 weeks of medical treatment.
Thank you for your consideration.
Sincerely,
[Your Name]
Patient Advocate | Dear Sir/Madam,
I am writing on behalf of [Patient Name], a female enrollee who is requesting Harvoni for 12 weeks of medical treatment for her hepatitis C virus genotype 1a.
After reviewing the independent medical review findings, we, as an advocate for the I, believe that the requested treatment should be considered medically necessary.
According to the most recent 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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to nonliver-related comorbid conditions. Given that [Patient Name] does not fit into any of these exclusion criteria, we believe that she is eligible for treatment.
Furthermore, Is who have failed treatment with peginterferon-based regimens are recommended to be re-treated with daily Harvoni for 12 weeks. Since [Patient Name] has failed previous treatment regimens, we believe that she would be a good candidate for this treatment.
Based on published evidence of safety and efficacy in the medical literature, and clinical guidelines, we support my request for Harvoni for 12 weeks of medical treatment.
Thank you for your consideration.
Sincerely,
[Your Name]
Patient Advocate |
[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 external board review found that a female enrollee requested Harvoni for 12 weeks for medical treatment of her hepatitis C virus genotype 1a. Based on clinical guidelines and published evidence, the requested treatment consisting of Harvoni for 12 weeks should be considered medically necessary in this patient's case.[/INST] | The treatment of Harvoni for 12 weeks is considered medically necessary because based on the most recent 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, regardless of fibrosis, should be treated except those with a life expectancy less than 12 months due to non-liver-related comorbid conditions. Iin question had not failed previous treatment with peginterferon-based regimens, which suggests that she does not meet this exclusion criterion. Furthermore, the requested treatment of Harvoni for 12 weeks has been shown to be safe and effective in the medical literature, and is in line with clinical guidelines. Therefore, the treatment is considered medically necessary in my case. | The treatment of Harvoni for 12 weeks is considered medically necessary because based on the most recent 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, regardless of fibrosis, should be treated except those with a life expectancy less than 12 months due to non-liver-related comorbid conditions. Iin question had not failed previous treatment with peginterferon-based regimens, which suggests that she does not meet this exclusion criterion. Furthermore, the requested treatment of Harvoni for 12 weeks has been shown to be safe and effective in the medical literature, and is in line with clinical guidelines. Therefore, the treatment is considered medically necessary in my 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 requested independent medical review found that:
* The enrollee requested reimbursement for a SPECT-DAT scan to evaluate worsening symptoms in patients with movement disorders.
* Clinically establishing a diagnosis is critical for clinical management.
* The SPECT-DAT can reliably distinguish between Parkinsons disease and other parkinsonian syndromes associated with nigrostriatal degeneration.
* SPECT-DAT is considered reasonable for patients in whom the diagnosis is unclear after clinical evaluation.
* Two of the three
All three reviewers are board-certified in neurology and actively practicing, and have expertise in the treatment of the enrollee's medical condition through recent or current clinical experience.[/INST] | [Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Date]
[Insurance Provider's Name]
[Insurance Provider's Home Office Address]
[City, State, ZIP Code]
Dear Sir/Madam,
I am writing to you on behalf of [Enrollee's Name], a I who has recently been denied coverage for a requested medical procedure.
We understand that [Enrollee's Name] has been diagnosed with [medical condition] and has been recommended to undergo a Single Photon Emission Computed Tomography Dopamine Transporter (SPECT-DAT) scan by their treating physician. This procedure is recommended by healthcare guidelines to establish a diagnosis and provide further information about the enrollee's medical condition.
The SPECT-DAT scan was performed by a qualified healthcare professional and definitively established the diagnosis of [medical condition]. The results demonstrated a dopaminergic abnormality and were consistent with Parkinson's disease. The accuracy and reliability of SPECT-DAT in the diagnosis and differentiation of parkinsonian syndromes is well-established and the examination was securely implemented.
Despite the recommendation from the physician and the diagnostic confirmation, the insurance plan denied coverage for the SPECT-DAT scan on the basis of experimental/investigational status. This decision has caused unnecessary distress and inconvenience to [Enrollee's Name] and has delayed their proper medical treatment.
We urge you to reconsider this decision and provide coverage for the SPECT-DAT scan. This examination is approved for striatal dopamine transporter visualization to assist in the assessment of adult Is with suspected parkinsonian syndromes and has been proven to be beneficial in the diagnosis and treatment of [medi | [Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Date]
[Insurance Provider's Name]
[Insurance Provider's Home Office Address]
[City, State, ZIP Code]
Dear Sir/Madam,
I am writing to you on behalf of [Enrollee's Name], a I who has recently been denied coverage for a requested medical procedure.
We understand that [Enrollee's Name] has been diagnosed with [medical condition] and has been recommended to undergo a Single Photon Emission Computed Tomography Dopamine Transporter (SPECT-DAT) scan by their treating physician. This procedure is recommended by healthcare guidelines to establish a diagnosis and provide further information about the enrollee's medical condition.
The SPECT-DAT scan was performed by a qualified healthcare professional and definitively established the diagnosis of [medical condition]. The results demonstrated a dopaminergic abnormality and were consistent with Parkinson's disease. The accuracy and reliability of SPECT-DAT in the diagnosis and differentiation of parkinsonian syndromes is well-established and the examination was securely implemented.
Despite the recommendation from the physician and the diagnostic confirmation, the insurance plan denied coverage for the SPECT-DAT scan on the basis of experimental/investigational status. This decision has caused unnecessary distress and inconvenience to [Enrollee's Name] and has delayed their proper medical treatment.
We urge you to reconsider this decision and provide coverage for the SPECT-DAT scan. This examination is approved for striatal dopamine transporter visualization to assist in the assessment of adult Is with suspected parkinsonian syndromes and has been proven to be beneficial in the diagnosis and treatment of [medi |
[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 found that:
* The enrollee requested reimbursement for a SPECT-DAT scan to evaluate worsening symptoms in patients with movement disorders.
* Clinically establishing a diagnosis is critical for clinical management.
* The SPECT-DAT can reliably distinguish between Parkinsons disease and other parkinsonian syndromes associated with nigrostriatal degeneration.
* SPECT-DAT is considered reasonable for patients in whom the diagnosis is unclear after clinical evaluation.
* Two of the three
All three reviewers are board-certified in neurology and actively practicing, and have expertise in the treatment of the enrollee's medical condition through recent or current clinical experience.[/INST] | The treatment considered medically necessary was the SPECT-DAT scan, which is recommended according to practice guidelines for the evaluation of movement disorders and is considered reliable for differentiating Parkinsons disease from essential tremor. The reviewers found that an accurate diagnosis is critical for clinical management, and the SPECT-DAT scan is considered reasonable for Is in whom the diagnosis is unclear after clinical evaluation. Two of the three reviewers determined that the requested services were likely to be more beneficial than any available standard therapy. | The treatment considered medically necessary was the SPECT-DAT scan, which is recommended according to practice guidelines for the evaluation of movement disorders and is considered reliable for differentiating Parkinsons disease from essential tremor. The reviewers found that an accurate diagnosis is critical for clinical management, and the SPECT-DAT scan is considered reasonable for Is in whom the diagnosis is unclear after clinical evaluation. Two of the three reviewers determined that the requested services were likely to be more beneficial than any available standard therapy. |
[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 that a 31-year-old female enrollee has requested urgent care services on the said date. The reviewer found that in this case, the absence of immediate medical attention on the date in question could reasonably be expected to result in any of the clinical medical conditions mentioned, such as pyelonephritis, hydronephrosis, malignancy, liver dysfunction etc which would have placed the patient’s health in serious jeopardy. Therefore, the patient's symptoms on the date in question met prudent layperson criteria for emergency care and grounds were urgent care.[/INST] | Thank you for providing me with the original appeal by the I. It appears that the I is requesting urgent care services from their determine physician based on their presenting symptoms. The physician has reviewed the clinical documentation and found that my symptoms meet the criteria for an emergency medical condition under California law. The symptoms in question were painful urination, blood clots in urine, frequency, urgency, back pain, abdominal pain, and yellow appearing skin. Based on these symptoms, the physician has determined that the I should receive urgent care.
Ihe I, who wants to receive urgent medical attention. My symptoms are consistent with several medical conditions that could have resulted in serious jeopardy to their health, such as pyelonephritis, hydronephrosis, malignancy, liver dysfunction, and others. Iis requesting the physician to provide immediate medical attention as they feel that their health is at serious risk. | Thank you for providing me with the original appeal by the I. It appears that the I is requesting urgent care services from their determine physician based on their presenting symptoms. The physician has reviewed the clinical documentation and found that my symptoms meet the criteria for an emergency medical condition under California law. The symptoms in question were painful urination, blood clots in urine, frequency, urgency, back pain, abdominal pain, and yellow appearing skin. Based on these symptoms, the physician has determined that the I should receive urgent care.
Ihe I, who wants to receive urgent medical attention. My symptoms are consistent with several medical conditions that could have resulted in serious jeopardy to their health, such as pyelonephritis, hydronephrosis, malignancy, liver dysfunction, and others. Iis requesting the physician to provide immediate medical attention as they feel that their health is at serious risk. |
[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 that a 31-year-old female enrollee has requested urgent care services on the said date. The reviewer found that in this case, the absence of immediate medical attention on the date in question could reasonably be expected to result in any of the clinical medical conditions mentioned, such as pyelonephritis, hydronephrosis, malignancy, liver dysfunction etc which would have placed the patient’s health in serious jeopardy. Therefore, the patient's symptoms on the date in question met prudent layperson criteria for emergency care and grounds were urgent care.[/INST] | The provider's analysis considered my urgent care request and found that her absence of immediate medical attention could have resulted in serious jeopardy to her health. My symptoms, such as painful urination and blood clots in her urine, were consistent with a number of potentially serious medical conditions, including pyelonephritis, hydronephrosis, malignancy, and liver dysfunction. As such, the services requested were considered medically necessary under California law, as they were necessary to treat my condition and prevent further harm to her health. | The provider's analysis considered my urgent care request and found that her absence of immediate medical attention could have resulted in serious jeopardy to her health. My symptoms, such as painful urination and blood clots in her urine, were consistent with a number of potentially serious medical conditions, including pyelonephritis, hydronephrosis, malignancy, and liver dysfunction. As such, the services requested were considered medically necessary under California law, as they were necessary to treat my condition and prevent further harm to her health. |
[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 submitting your appeal for coverage of transcatheter arterial chemoembolization (TACE) treatments for your liver cancer. We understand that TACE is being recommended by your healthcare providers for potential clinical benefit, but our plans only cover treatments that have been proven safe and effective through rigorous clinical investigation.
Based on our review of the submitted records, we have determined that TACE is not considered a standard therapy for liver cancer and is currently being considered experimental for the treatment of your particular condition. The independent medical review findings indicate that there is significant variation in hepatocellular carcinoma, making it difficult to establish the efficacy of TACE in clinical studies. While there are studies that show good response rates, the consensus in oncology is that TACE is the only treatment that is at all likely to be beneficial in the treatment of hepatocellular carcinoma that can neither be resected nor treated with liver transplantation.
Therefore, we are unable to cover the TACE treatments that have been recommended for your condition. If you have any further questions regarding this decision, please do not hesitate to contact us.
Sincerely,
[Your Name]
[Your Title]
[Your Contact Information][/INST] | The review found that for the 62-year-old man, TACE was likely to be more beneficial for treatment of his hepatocellular carcinoma than any available standard therapy. The man had previously undergone TACE in May and June 2004, with a dramatic fall in the tumor marker (AFP) and a decrease in the size of the mass, and was found to be doing well clinically. Therefore, based on this evidence, TACE should be considered medically necessary for this I. | The review found that for the 62-year-old man, TACE was likely to be more beneficial for treatment of his hepatocellular carcinoma than any available standard therapy. The man had previously undergone TACE in May and June 2004, with a dramatic fall in the tumor marker (AFP) and a decrease in the size of the mass, and was found to be doing well clinically. Therefore, based on this evidence, TACE should be considered medically necessary for this I. |
[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 submitting your appeal for coverage of transcatheter arterial chemoembolization (TACE) treatments for your liver cancer. We understand that TACE is being recommended by your healthcare providers for potential clinical benefit, but our plans only cover treatments that have been proven safe and effective through rigorous clinical investigation.
Based on our review of the submitted records, we have determined that TACE is not considered a standard therapy for liver cancer and is currently being considered experimental for the treatment of your particular condition. The independent medical review findings indicate that there is significant variation in hepatocellular carcinoma, making it difficult to establish the efficacy of TACE in clinical studies. While there are studies that show good response rates, the consensus in oncology is that TACE is the only treatment that is at all likely to be beneficial in the treatment of hepatocellular carcinoma that can neither be resected nor treated with liver transplantation.
Therefore, we are unable to cover the TACE treatments that have been recommended for your condition. If you have any further questions regarding this decision, please do not hesitate to contact us.
Sincerely,
[Your Name]
[Your Title]
[Your Contact Information][/INST] | appeal by the I: During my recent independent medical review, Physician 1 determined that transcatheter arterial chemoembolization (TACE) is likely to be more beneficial for my medical condition (unresectable hepatocellular carcinoma) than any available standard therapy. TACE involves infusion of chemotherapy drugs directly into the hepatic arteries that feed cancerous tumors.
However, even though there is growing support for the use of TACE in treating hepatocellular carcinoma, the Health Plan denied coverage for TACE, citing it as an experimental treatment. The physician noted that I have had two TACE treatments already, and follow-up MRI has shown diminution of the size of the left portal vein mass. I feel that TACE has worked well for me as I have remained asymptomatic post-TACE treatments.
Physician 2, in his review, echoed the sentiments of Physician 1. While the role of TACE in the management of hepatocellular carcinoma is incompletely defined, he noted that for Is with unresectable disease, there is conflicting evidence as to whether TACE prolongs survival and even though some studies have demonstrated a survival advantage, others have not.
However, there are consistent findings of significant palliation manifested by decreased pain and better control of the disease within the liver. Given my unresectable situation and the stable condition of my liver MRI, TACE should be considered as an acceptable palliative therapy especially for Is with significant symptoms, though the survival benefit has not been clearly defined.
Physician 3, in his review, notes that TACE has been shown to be particularly effective in inoperable hepatocellular carcinoma, noting a dramatic reduction in Alpha-fetoprotein (AFP) in the last case. While the Health Plan has denied TACE based on experimental status, the physician notes that there is no evidence to suggest that any standard therapy is more effective.
In conclusion, based on the independent medical review findings, I believe that TACE is likely to be more beneficial for my medical condition than any available standard therapy. I request that the Health Plan overturn its denial of TACE coverage for treatments in May 2004 and June 2004 and allow me to receive additional TACE treatments. | appeal by the I: During my recent independent medical review, Physician 1 determined that transcatheter arterial chemoembolization (TACE) is likely to be more beneficial for my medical condition (unresectable hepatocellular carcinoma) than any available standard therapy. TACE involves infusion of chemotherapy drugs directly into the hepatic arteries that feed cancerous tumors.
However, even though there is growing support for the use of TACE in treating hepatocellular carcinoma, the Health Plan denied coverage for TACE, citing it as an experimental treatment. The physician noted that I have had two TACE treatments already, and follow-up MRI has shown diminution of the size of the left portal vein mass. I feel that TACE has worked well for me as I have remained asymptomatic post-TACE treatments.
Physician 2, in his review, echoed the sentiments of Physician 1. While the role of TACE in the management of hepatocellular carcinoma is incompletely defined, he noted that for Is with unresectable disease, there is conflicting evidence as to whether TACE prolongs survival and even though some studies have demonstrated a survival advantage, others have not.
However, there are consistent findings of significant palliation manifested by decreased pain and better control of the disease within the liver. Given my unresectable situation and the stable condition of my liver MRI, TACE should be considered as an acceptable palliative therapy especially for Is with significant symptoms, though the survival benefit has not been clearly defined.
Physician 3, in his review, notes that TACE has been shown to be particularly effective in inoperable hepatocellular carcinoma, noting a dramatic reduction in Alpha-fetoprotein (AFP) in the last case. While the Health Plan has denied TACE based on experimental status, the physician notes that there is no evidence to suggest that any standard therapy is more effective.
In conclusion, based on the independent medical review findings, I believe that TACE is likely to be more beneficial for my medical condition than any available standard therapy. I request that the Health Plan overturn its denial of TACE coverage for treatments in May 2004 and June 2004 and allow me to receive additional TACE treatments. |
[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 independent medical review findings were:
The patient is a 19-year old male with disabling chronic daily headaches who was seen at an out of state facility for additional medical opinions. He was previously seen by many neurologists, headache specialists, and pain management physicians. The patient underwent diagnostic testing of the brain (MRI/MRV/MRA) in September 2004. The consulting reviewer, a neurologist, examined the films and ordered an additional MRV with contrast, which was performed on 1/26/05. Upon reviewing the clinical evidence, the reviewer determined the MRV at issue was medically necessary to rule out superior sagittal venous sinus thrombosis and for comparison with the September 2004 MRI to better evaluate an anomaly in that study. Therefore, the grounds for the initial denial of coverage were medical necessity.[/INST] | Dear [Health Plan],
I am writing on behalf of I in regards to the denial of coverage for an additional MRI with contrast of the brain. Iis a 19-year-old male with disabling chronic daily headaches who has undergone evaluation by numerous neurologists, headache specialists, and pain management physicians.
After undergoing diagnostic testing of the brain (MRI/MRV/MRA) in September 2004, my consulting physician ordered an additional MRV with contrast on 1/26/05. The Health Plan denied coverage, stating that the MRI was not medically necessary.
In reviewing the submitted clinical evidence, I have determined that the additional MRI was necessary to rule out superior sagittal venous sinus thrombosis and for comparison with the September 2004 MRA to better evaluate an anomaly in that study. Given the clinical objectives of the repeat study and the medical necessity of the procedure, I urge you to overturn the denial of coverage.
Sincerely,
[Your Name] | Dear [Health Plan],
I am writing on behalf of I in regards to the denial of coverage for an additional MRI with contrast of the brain. Iis a 19-year-old male with disabling chronic daily headaches who has undergone evaluation by numerous neurologists, headache specialists, and pain management physicians.
After undergoing diagnostic testing of the brain (MRI/MRV/MRA) in September 2004, my consulting physician ordered an additional MRV with contrast on 1/26/05. The Health Plan denied coverage, stating that the MRI was not medically necessary.
In reviewing the submitted clinical evidence, I have determined that the additional MRI was necessary to rule out superior sagittal venous sinus thrombosis and for comparison with the September 2004 MRA to better evaluate an anomaly in that study. Given the clinical objectives of the repeat study and the medical necessity of the procedure, I urge you to overturn the denial of coverage.
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 independent medical review findings were:
The patient is a 19-year old male with disabling chronic daily headaches who was seen at an out of state facility for additional medical opinions. He was previously seen by many neurologists, headache specialists, and pain management physicians. The patient underwent diagnostic testing of the brain (MRI/MRV/MRA) in September 2004. The consulting reviewer, a neurologist, examined the films and ordered an additional MRV with contrast, which was performed on 1/26/05. Upon reviewing the clinical evidence, the reviewer determined the MRV at issue was medically necessary to rule out superior sagittal venous sinus thrombosis and for comparison with the September 2004 MRI to better evaluate an anomaly in that study. Therefore, the grounds for the initial denial of coverage were medical necessity.[/INST] | The treatment is considered medically necessary because it aligned with my clinical objectives and was necessary to rule out and better evaluate a medical condition. The MRI with contrast was determined to be necessary to accurately diagnose and treat my disabling chronic daily headaches, which had previously been evaluated by many healthcare providers. The initial MRI without contrast in September 2004 had identified an anomaly that warranted further evaluation with a MRV with contrast. Based on this information, the independent medical review found that the repeat MRV was medically necessary for my condition. | The treatment is considered medically necessary because it aligned with my clinical objectives and was necessary to rule out and better evaluate a medical condition. The MRI with contrast was determined to be necessary to accurately diagnose and treat my disabling chronic daily headaches, which had previously been evaluated by many healthcare providers. The initial MRI without contrast in September 2004 had identified an anomaly that warranted further evaluation with a MRV with contrast. Based on this information, the independent medical review found that the repeat MRV was medically necessary for my 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 Findings: we found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Fiasp injection 100 units/mL. Multiple daily injections, which involve several shots of short-acting prandial insulin, along with one to two doses of a long-acting basal preparation, are oftentimes recommended for management of type 1 diabetes. One study noted that randomised controlled trials have shown an advantage of continuous subcutaneous insulin infusion (CSII) over multiple daily injections (MDI) in the general type 1 diabetes mellitus (T1DM) population. Various options for prandial insulins are currently available. Researchers found that fast-acting insulin aspart (Fiasp), is insulin aspart in a new formulation aiming to mimic the physiologic prandial insulin release more closely than available rapid-acting insulin products. The records indicate that this patient has responded well to Fiasp, unlike the suboptimal response to other prandial insulins. For these reasons, the requested Fiasp injection 100 units/mL is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans decision to deny coverage should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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] | Subject: Appeal for Fiasp Injection 100 Units/mL Coverage
Dear [Insurance Provider],
Iyself as a I with type 1 diabetes. Over the past several months, I have been experiencing difficulties with my blood sugar levels when administering other prandial insulin options due to slower or irregular absorption. This has led to unstable blood sugar levels and raised concerns for my overall health and well-being.
After numerous discussions with my doctor, he recommended a change in treatment to Fiasp injection 100 units/mL, a rapid-acting insulin aspart formulation in a new formulation that aims to mimic the physiologic prandial insulin release more closely than available rapid-acting insulin products. I have noticed significant improvements in my blood sugar management since starting Fiasp compared to previous insulin options, demonstrating a suboptimal response.
I understand that Fiasp is a relatively new product on the market, but it has shown promise in multiple clinical studies and has proven effective in managing my blood sugar levels. My doctor, a board-certified internal medicine specialist with subspecialty certification in endocrinology, diabetes, and metabolism, believes that continuing to use the Fiasp injection 100 units/mL is essential for the effective management of my type 1 diabetes.
Therefore, I am requesting that my insurance provider approves the coverage for the Fiasp injection 100 units/mL for my ongoing treatment. The medical necessity for this coverage is evident, and I feel confident that this new treatment plan will significantly improve my blood sugar management and overall quality of life.
Thank you for your consideration and prompt review of this request. I look forward to receiving a favorable response soon.
Sincerely,
[Your Name] | Subject: Appeal for Fiasp Injection 100 Units/mL Coverage
Dear [Insurance Provider],
Iyself as a I with type 1 diabetes. Over the past several months, I have been experiencing difficulties with my blood sugar levels when administering other prandial insulin options due to slower or irregular absorption. This has led to unstable blood sugar levels and raised concerns for my overall health and well-being.
After numerous discussions with my doctor, he recommended a change in treatment to Fiasp injection 100 units/mL, a rapid-acting insulin aspart formulation in a new formulation that aims to mimic the physiologic prandial insulin release more closely than available rapid-acting insulin products. I have noticed significant improvements in my blood sugar management since starting Fiasp compared to previous insulin options, demonstrating a suboptimal response.
I understand that Fiasp is a relatively new product on the market, but it has shown promise in multiple clinical studies and has proven effective in managing my blood sugar levels. My doctor, a board-certified internal medicine specialist with subspecialty certification in endocrinology, diabetes, and metabolism, believes that continuing to use the Fiasp injection 100 units/mL is essential for the effective management of my type 1 diabetes.
Therefore, I am requesting that my insurance provider approves the coverage for the Fiasp injection 100 units/mL for my ongoing treatment. The medical necessity for this coverage is evident, and I feel confident that this new treatment plan will significantly improve my blood sugar management and overall quality of life.
Thank you for your consideration and prompt review of this request. I look forward to receiving a favorable response soon.
Sincerely,
[Your Name] |