Acne denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: According to the records, the enrollee is requesting consultation with a dermatologist. Internal medicine notes indicate the enrollee has hormonal acne treated with medicated face wash that over-dried her skin and a skin lesion on her face. A referred dermatologist documented jawline inflammatory papules and pustules and scars distributed on her face. Prescribed were Retin-A micro topical gel, spironolactone, and clindamycin 1% lotion. A follow-up visit noted that spironolactone made her nauseous and topical treatment was fine, but she was still having breakouts. Acne was improved, but still present and prescribed was the antibiotic, Doxycycline. On the next visit, her acne was the same, skin was almost clear. Prescribed was Aczone 7.5% topical gel and Retin-A Micro gel was continued.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Yaz for treatment of her bleeding with other birth control medications. Findings: The physician reviewer found that for the symptoms that the patient has described, most oral contraceptive pills will improve her symptoms. However, there is evidence that those oral contraceptive pills with drospirenone are superior for women with for acne and premenstrual mood deterioration. As this patient has tried multiple oral contraceptive pills including the formulary’s generic for Yaz, without adequate control of her symptoms, it is reasonable for the patient to be continued on Yaz as it provides the best control of her symptoms. Also, taking the medication in a continuous manner works to improve migraine symptoms.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee has requested coverage for Claravis 30 mg capsules which was denied by the health plan as not medically necessary. The records indicate the enrollee has had acne for many years. Provider notes indicate treatment has included oral and topical antibiotics as well as Retin A. It is noted the patient was on two different oral antibiotics for nine months. According to current literature, the utilization of isotretinoin (Claravis) is typically recommended for severe recalcitrant nodular acne. Severe by definition, is proven by many as opposed to fewer or several nodules. Nodules are typically defined as inflammatory lesions with a diameter of 5 mm or greater. The submitted documentation does not include clinical notes detailing the above. The documentation does not detail the enrollee has evidence of severe recalcitrant nodular acne.

Nature of Statutory Criteria/Case Summary: The parent of the patient has requested authorization and coverage for Absorica 25 mg tablet, once a day. A high-fat meal is needed for optimal absorption of isotretinoin. Absorica, isotretinoin-Lidose, is a specialized formulation of isotretinoin that enhances absorption of isotretinoin in the absence of dietary fat and may be used with patients who are unable to take medication with food. Vegetarianism in and of itself is not a medical indication for the use of Absorica, as there are non-meat alternatives with high fat content, including nuts and oils. In this case, the use of isotretinoin-Lidose is not medically indicated over the use of isotretinoin. Therefore, Absorica 25 mg tablet, once a day is not medically necessary for the treatment of this patient.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving acne, then check the rights and deadlines that apply to your plan.