Keloid denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for (1) a referral to a skin laser specialist, (2) a 585-nm flashlamp pumped pulsed dye laser/CO2 laser specific for scars, and (3) a higher dosage of Kenalog 40 mg. Jin and colleagues report that the management of hypertrophic scars and keloids remains a therapeutic challenge, and that while laser therapy is an emerging minimally invasive treatment that has recently gained attention, the level of evidence for laser therapy as a keloid treatment is low. The authors conclude that further research is required to determine the mechanism of action for different laser systems and to examine the efficacy in quantifiable parameters, such as scar erythema, scar texture, degrees of symptom relief, recurrence rates, and adverse effects.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated carbon dioxide (CO2) laser to the bilateral face, scalp, chest, abdomen, left shoulder, and groin with topical application of 5-fluorouracil (5FU). Intralesional injection with triamcinolone acetonide (TAC) represents the gold standard in the treatment of keloids, with the fastest response. Fractionated CO2 has been demonstrated to be as efficient, and possibly more effective, than TAC for some patients. Given the severe symptoms associated with this patient’s disease including infection and purulent drainage, he would most likely benefit from TAC combined with fractionated CO2.

Where the denial was upheld

A 50-year-old female enrollee has requested a keloid and scar removal procedure for the treatment of her condition. Findings: The physician reviewer found that the submitted clinical evidence does not establish that the procedure at issue was reconstructive in nature. This patient presented with keloid scars following breast reduction for macromastia. Thus, she had an abnormal structure caused by trauma, specifically, breast reduction surgery. However, the procedure at issue was not likely to result in more than a minimal improvement in the appearance of the patient as surgical excision of a keloid without postoperative steroid injections carries a significant chance of recurrence. Thus, the procedure at issue does not meet the definition of reconstructive surgery as defined by California law.

The parent of a 17-year-old female enrollee has requested surgical removal of keloid scars from the ear for the treatment of the enrollee’s keloid scars. Findings: The physician reviewer found that a keloid is a scar, and scars are normal occurrences. It would only be considered abnormal with photographic documentation of a very large size, or documented symptoms of pain interfering with function, sleep, loss of range of motion/mobility or recurrent infections in the keloid. In this patient’s case, the submitted documentation does not demonstrate that the keloid is an abnormal structure of the body. The medical records do not demonstrate that the requested surgery will be performed to improve function. Given the lack of photographs, there is no evidence that the requested surgery will offer more than a minimal improvement in the appearance of the 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 keloid, then check the rights and deadlines that apply to your plan.