Cyst: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a sacral laminectomy, spinal dorsa graft and osteoplastic reconstruction of dorsal spinal elements following a primary intraspinal procedure of her lower back. Findings: The physician reviewer found that there is evidence based medical peer-reviewed literature that supports the use of microsurgical resection of Tarlov cysts as safe and effective treatment for symptomatic Tarlov cysts. Studies indicate that symptomatic Tarlov cysts are extremely rare. Burke and colleagues completed one of the largest published studies on patients with Tarlov cysts who were treated microsurgically. They studied 23 adults who were treated with laminectomy, microsurgical exposure and/or imbrication, and para-spinous muscle flap closure.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for laser hair removal. The records provided for review document that this patient presents with excessive hair about the buttocks and gluteal cleft. The patient’s age, gender, and hirsutism are all risk factors for the development and recurrence of pilonidal cysts. Pilonidal cysts are characterized by chronic and recurrent inflammation and infection surrounding hair on the buttocks and gluteal cleft. Surgical treatments have a high rate of recurrence and often require repeated surgical interventions and systemic antibiotics for the accompanying folliculitis and cellulitis (Kelati, et al.).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of the cyst on his right shoulder. While incision and debridement along with antibiotics are appropriate for treating an abscess, an epidermoid cyst is an encapsulated subepidermal nodule filled with keratin and most commonly located on the face, neck, and trunk. Cysts may progress slowly and remain present for years. Most cysts are sporadic, the most common being cutaneous cysts, typically occurring in the third and fourth decades of life. They are predominantly found in males. Generally, the cysts are asymptomatic until they rupture. Options for management include continued observation or complete surgical excision of the cyst with the cyst wall intact to decrease recurrence.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for pilonidal cyst laser ablation (Sinus Laser Closure [SiLaC]). Pilonidal disease is a chronic, suppurative condition that typically occurs in the sacrococcygeal region and may have periods of inactivity and recurrence. While multiple treatment options exist, newer techniques such as SiLaC are still being evaluated and are not considered standard therapy. Comparative studies have shown that traditional surgical approaches, such as flap closure, demonstrate better healing outcomes than SiLaC. Additional studies comparing laser treatment to excision techniques have reported higher rates of residual disease and recurrence with laser therapy. Overall, current medical literature does not support SiLaC as superior to established surgical treatments.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for cyst was denied, the published record says the denial is worth fighting.