From Denial to Approval

You’ve just spent a solid hour on the phone with an insurance company, only to hear the dreaded words, “We regret to inform you that the treatment has been denied.” You hang up, take a deep breath, and wonder if the insurance reps moonlight as stone walls. Your patient with severe psoriasis is counting on this biologic treatment, but now you’re stuck writing an appeal letter that feels like it needs to be a mix of legal brief and impassioned plea.

Enter ChatGPT. It’s like having a virtual assistant who’s read all the dermatology journals and knows just how to word things to make insurance companies sit up and listen. Today, we’re going to show you how to take a basic prompt and turn it into a letter that not only makes your case but backs it up with references. And while ChatGPT is great at pulling together persuasive arguments, we’ll also guide you through spotting those pesky AI “hallucinations”—the moments when it confidently spits out information that sounds right but might actually be a little off. Because if you’re going to battle an insurance company, you might as well bring some heavy (and smart) artillery, and that includes knowing when your AI assistant might need a reality check.

Step 1: Start with a Basic Prompt

Begin with a simple prompt like: "Write a letter of appeal for a denied insurance claim for secukinumab for a patient with severe psoriasis."

This first draft honestly isn’t that bad, but some of the details might not accurately describe the patient’s history. Plus it just has placeholders for specific pieces of info — like “[Patient’s Full Name]”.

[Your Name]  
[Your Address]  
[City, State, ZIP Code]  
[Email Address]  
[Phone Number]  
[Date]

**Re: Appeal for Denied Claim for Secukinumab (Cosentyx) for [Patient's Full Name]**  
**Policy Number:** [Policy Number]  
**Claim Number:** [Claim Number]

**To Whom It May Concern:**

I am writing on behalf of my patient, [Patient's Full Name], to appeal the denial of coverage for Secukinumab (Cosentyx) prescribed for the treatment of their severe psoriasis. I believe this decision does not consider the severity of the patient's condition or the established medical necessity for this specific treatment.

### **Patient History and Condition**

[Patient's Full Name] has been under my care for [duration of treatment] for severe plaque psoriasis, a chronic and debilitating condition that significantly impacts their quality of life. Despite multiple treatment regimens, including topical therapies, phototherapy, and systemic treatments such as methotrexate and cyclosporine, [Patient's Full Name] has not experienced adequate symptom control. The patient continues to suffer from extensive plaques, severe pruritus, and discomfort, which substantially affect their daily activities and emotional well-being.

### **Rationale for Secukinumab (Cosentyx) Treatment**

Secukinumab, an IL-17A inhibitor, is indicated for the treatment of moderate to severe plaque psoriasis in patients who are candidates for systemic therapy or phototherapy. Given the patient's refractory response to previous therapies and the severity of their disease, Secukinumab offers a well-established and FDA-approved option that is supported by clinical guidelines and evidence.

**Supporting Evidence:**

1. **Clinical Guidelines:** The American Academy of Dermatology's guidelines on the management of psoriasis recommend IL-17 inhibitors, including Secukinumab, as effective treatment options for patients with moderate to severe plaque psoriasis, particularly when other systemic treatments have failed.

2. **Efficacy and Safety:** Multiple clinical trials have demonstrated that Secukinumab is highly effective in achieving and maintaining significant skin clearance in patients with severe plaque psoriasis. Furthermore, the safety profile of Secukinumab has been extensively evaluated, showing a favorable risk-benefit ratio, particularly for patients like [Patient's Full Name] who have not responded to other treatments.

3. **Individualized Care:** In [Patient's Full Name]'s case, the unique pharmacological action of Secukinumab, targeting the IL-17 pathway, addresses the specific pathophysiological mechanisms driving their severe psoriasis. This individualized approach is crucial to managing their condition effectively and preventing further physical and psychological distress.

### **Conclusion**

Denying coverage for Secukinumab not only contradicts established clinical guidelines but also puts [Patient's Full Name] at risk for ongoing suffering and potential complications associated with uncontrolled psoriasis. I strongly urge you to reconsider this decision and approve the claim for Secukinumab, allowing [Patient's Full Name] to access the treatment they urgently need.

Thank you for your attention to this appeal. I am happy to provide any additional information or documentation that may assist in the reconsideration of this claim. Please do not hesitate to contact me directly at [Your Phone Number] or [Your Email Address].

Sincerely,  
[Your Full Name, MD]  
[Your Medical Practice Name]  
[Your Address]  
[City, State, ZIP Code]  
[Phone Number]  
[Email Address]  

---

**Attachments:**

- Clinical Notes
- Previous Treatment History
- Relevant Clinical Guidelines
- Peer-Reviewed Articles on Secukinumab Efficacy and Safety

Step 2: Add Specific Details

Now, let’s get specific. For instance, we can follow-up by telling ChatGPT: “The patient’s psoriasis specifically affects areas on the scalp, elbows, and lower back, and replace [Patient’s Full Name] with Jane Doe. ”.

...

**To Whom It May Concern:**

I am writing on behalf of my patient, Jane Doe, to appeal the denial of coverage for Secukinumab (Cosentyx) prescribed for the treatment of her severe psoriasis. I believe this decision does not consider the severity of the patient’s condition or the established medical necessity for this specific treatment.

### **Patient History and Condition**

Jane Doe has been under my care for [duration of treatment] for severe plaque psoriasis, a chronic and debilitating condition that significantly impacts her quality of life. Despite multiple treatment regimens, including topical therapies, phototherapy, and systemic treatments such as methotrexate and cyclosporine, Jane has not experienced adequate symptom control. Her psoriasis specifically affects areas on the scalp, elbows, and lower back, causing severe pruritus, pain, and discomfort that interfere with her daily activities and emotional well-being.

...

So, ChatGPT swaps out "[Patient’s Full Name]" with "Jane Doe," and suddenly it decides to switch all references to "the patient" with "she/her" pronouns. Classic AI "hallucination" moment! Here’s what’s happening: the AI is taking liberties and assuming that "Jane Doe" must be a woman, which wasn’t part of your instructions. This is an example of what’s called a toxic behavior hallucination because it reinforces stereotypes and could lead to misgendering—definitely not what you want, especially in a medical context where accuracy and respect are key.

Why does it make this mistake? Well, ChatGPT is trained on a massive amount of text from the internet, where names like "Jane" are often associated with female pronouns. So, the AI is basically guessing based on patterns it’s seen in its training data. But just because it’s seen something a lot doesn’t mean it’s always right—hence the occasional awkward, unintended slip-up. It’s a good reminder that while ChatGPT is smart, it sometimes makes assumptions that aren’t so smart, and we’ve got to keep an eye on it to avoid those mishaps.

Step 3: Ask for References

Citing references is like name-dropping reputable experts at a party—it instantly boosts your credibility and makes insurance companies take you (and your appeal) way more seriously. So to really seal the deal, you might say something like: "The letter needs more detailed references to clinical guidelines and studies. Can you cite specific recommendations from the American Academy of Dermatology (AAD) and include data from a recent study on the effectiveness of secukinumab in patients with severe plaque psoriasis?"

Check out this updated section for supporting evidence:

...

**Supporting Evidence:**

1. **American Academy of Dermatology (AAD) Guidelines:**
The AAD’s guidelines for the management of psoriasis and psoriatic arthritis, updated in 2019, recommend the use of IL-17 inhibitors, including Secukinumab, for patients with moderate to severe plaque psoriasis, particularly those who have failed to respond to other systemic agents. The guidelines highlight the efficacy and safety of Secukinumab, citing it as a first-line option for systemic therapy in patients who meet these criteria. The AAD specifically notes that “Secukinumab has demonstrated superior efficacy compared to placebo and etanercept in phase 3 clinical trials for moderate to severe plaque psoriasis” (AAD, 2019).

2. **Recent Clinical Data:**
A 2020 phase 3b trial published in The Lancet further supports the use of Secukinumab in severe cases. The study involved 1661 patients with moderate to severe plaque psoriasis who were randomized to receive either Secukinumab or placebo. The results showed that 81.6% of patients treated with Secukinumab achieved a PASI 75 (75% improvement in Psoriasis Area and Severity Index) response at week 12, compared to only 4.5% of patients receiving placebo. Moreover, 59.2% of the Secukinumab group achieved complete or almost complete skin clearance (PASI 90) at the same time point, demonstrating the drug’s high efficacy (Blauvelt et al., 2020).

3. **Efficacy and Safety Profile:**
Secukinumab’s mechanism of action, which targets the IL-17A cytokine, is particularly effective in treating the inflammatory processes underlying psoriasis. The safety profile of Secukinumab has been well-documented, with long-term studies showing sustained efficacy and a consistent safety profile, even in patients who have used the treatment for several years.

...

Now we’re talking! But hold on just a sec… ChatGPT might sound super confident but when it comes to accuracy, remember that it’s using patterns it’s learned from tons of text to whip up something that looks just right. Here’s the thing: it’s typically correct because it’s pulling from common citation styles and reputable sources it’s seen during training. But since it’s not actually connected to real-time databases, you’ll still want to double-check to make sure those references are the real deal. It’s like a solid first draft that just needs a quick fact-check.

Once you’re satisfied with the evidence, review the letter carefully and make sure it all aligns with your patient’s specific situation and add any personal touches that reflect your voice and professional judgment. This ensures that the letter is both compelling and true to your practice.

Coming up next…

There’s more where that came from! In our next issue, we’ll explore another tool or technique to make your practice run smoother and your life a little easier. Stay tuned—you won’t want to miss it!

Until next time,

The Wood's Lamp Editorial Team

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