Medical Necessity Letter
February 15, 2050
Blue Shield Health Insurance
1234 Healthcare Blvd
Springfield, IL 62701
Re: Medical Necessity for Genomic-Targeted Therapy (GTT-500)
Patient Name: Matthew Williams
Date of Birth: January 12, 2040
Policy Number: 789456123
Claim Number (if applicable): CLM20501234
Dear Mr. James Smith,
I am writing to provide medical justification for the necessity of Genomic-Targeted Therapy (GTT-500) for my patient, Matthew Williams, who has been under my care since February 2049. I am a board-certified oncologist (MD) licensed in Illinois, and my medical license number is IL1234567.
Patient Diagnosis and Medical History
Matthew Williams has been diagnosed with Stage III Non-Small Cell Lung Cancer (NSCLC), ICD-10 code C34.90, as of December 2049. This is a highly aggressive form of lung cancer that has metastasized to the lymph nodes. After careful evaluation of his condition and the available treatment options, it has been determined that Genomic-Targeted Therapy (GTT-500) is the most appropriate and necessary treatment for his case.
Matthew has already undergone conventional chemotherapy and radiation therapy, but his cancer has continued to progress. These standard treatments have proven to be insufficient, and based on his genomic profile, GTT-500 offers the best chance of targeting the specific mutations driving his cancer.
Rationale for Medical Necessity
The requested treatment, Genomic-Targeted Therapy (GTT-500), is essential for Matthew Williams due to the nature of his cancer, which harbors a rare mutation (EGFR-T790M). This mutation has rendered his cancer resistant to standard treatments, and without GTT-500, he faces a high likelihood of rapid disease progression, significant morbidity, and eventual mortality.
While GTT-500 is not typically covered under the current policy, it is specifically designed to target the EGFR mutation present in Matthew's tumor cells. Clinical trials and peer-reviewed studies have demonstrated that GTT-500 significantly improves survival rates and quality of life for patients with this mutation. Without this treatment, Matthew is at serious risk of tumor growth, metastasis to other organs, and a significant reduction in life expectancy.
I have attached supporting clinical documentation, including studies from Journal of Clinical Oncology and The Lancet Oncology, which validate the efficacy of GTT-500 in treating EGFR-positive NSCLC cases like Matthew’s.
Treatment Plan and Expected Outcome
Matthew Williams is expected to begin treatment with Genomic-Targeted Therapy (GTT-500) on March 1, 2050, and this course of treatment is anticipated to continue for 12 months, with regular monitoring of tumor markers and imaging to assess progress. The primary goals of this treatment are to halt tumor growth, induce partial remission, and improve Matthew's overall prognosis.
Given the severity of Matthew’s condition and the molecular profile of his cancer, I strongly recommend that Genomic-Targeted Therapy (GTT-500) be approved for coverage. This treatment is crucial for improving his survival and quality of life, and no other available treatments offer the same potential benefits.
Conclusion
I respectfully request that Blue Shield Health Insurance approve the coverage of Genomic-Targeted Therapy (GTT-500) for Matthew Williams. This therapy is medically necessary for the management of his cancer and is his best hope for a positive clinical outcome.
Should you require any additional information or documentation, please do not hesitate to contact me at [Your Company Number] or [Your Company Email].
Thank you for your attention to this matter, and I look forward to your prompt response.
Sincerely,
[Your Name]
Oncologist, Board Certified
[Your Company Name]
[Your Company Address]
[Your Company Number]
[Your Company Email]
License Number: IL1234567
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