Acne Vulgaris denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested doxycycline hydrate (Oracea) for treatment of her acne. The physician reviewer found that acne vulgaris is the most common dermatological disorder in adolescence and young adults. In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. The morphological characteristics of adult female acne are often distinct from adolescent acne. Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. Doxycycline has been approved by the U.S. Food and Drug Administration (FDA) as adjunctive therapy in severe acne. In adult female acne, the creation of papules, pustules and nodules is mediated through immune mechanisms.

Nature of Statutory Criteria/Case Summary: An enrollee has requested doxycycline hydrate (Oracea) for treatment of her acne. The physician reviewer found that acne vulgaris is the most common dermatological disorder in adolescence and young adults. In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. The morphological characteristics of adult female acne are often distinct from adolescent acne. Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. Doxycycline has been approved by the U.S. Food and Drug Administration (FDA) as adjunctive therapy in severe acne. In adult female acne, the creation of papules, pustules and nodules is mediated through immune mechanisms.

Where the denial was upheld

Physician 1: The patient is a 44-year-old male with long-standing acne vulgaris. He has been treated with multiple medications, both topical and oral, with only limited improvement. The patient underwent several Blu-light phototherapy sessions, a light based technology, to clear his acne and is now requesting reimbursement for the cost of the therapy. The Health Plan denied reimbursement citing the investigational nature of Blu-light phototherapy.At this time, the light therapies are an unproven treatment approach and there is very limited data comparing their efficacy with “traditional” acne therapies. A review of available research identified only one study in which the investigator was sponsored by the light source company. To date, there is no compelling evidence that the light-based therapies are likely to result in superior treatment outcomes.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Onexton gel pump. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s acne. A review of the record indicates that the enrollee has been diagnosed with acne. The medical records indicated the enrollee had acne present on the face, back, and chest. Papules, pustules, cysts, and erythema were noted. The enrollee was using Onexton gel and Retin-A. The enrollee’s provider has recommended Onexton gel pump for the enrollee.Acne vulgaris is the most common dermatological disorder in adolescence and young adults. In past decades, systemic antibiotics have had the main role in the treatment of acne patients with inflammatory papules and cysts.

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 vulgaris, then check the rights and deadlines that apply to your plan.