Nail Fungus denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jublia 10% topical solution. Findings: The physician reviewer found that Onychomycosis is a fungal infection of the nail which can result in pain, disfigurement, and secondary infection. Ulcerations of the nail bed as well as resultant osteomyelitis of the underlying phalanges may result, particularly in patients with peripheral neuropathy. Onychomycosis can be caused by dermatophytes, yeasts or nondermatophyte molds. The most common dermatophyte organisms that cause onychomycosis are Trichophyton rubrum and Trichophyton mentagrophytes. Diagnosis is made by patient history, physical findings, and diagnostic testing. Onychomycosis can be treated by oral and topical antifungals. Oral medications have systemic risks and so are not appropriate for all patients.

The enrollee is requesting authorization and coverage for reimbursement for toenail and callus trimming. The enrollee has diabetes mellitus, and was evaluated by a podiatrist for dermatophytosis of the toenails. Records showed the enrollee had a fungal infection of the toenails and an ulcer on the second toe of his left foot, which was debrided during the visit. He returned twice for the same complaints and underwent sharp debridement of 10 nails and four calluses on both visits. The enrollee reports he cannot feel his feet; therefore, he cannot determine how much nail or callus to remove before he cuts into his flesh and causes a wound. The enrollee’s diabetes causes foot wounds that do not heal normally, resulting in a risk of gangrene and possible amputation.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a 65-year-old female with a history of breast cancer and chemotherapy treatment. Findings: The physician reviewer found that ecords document a diagnosis of onychomycosis and tinea pedis. On 3/6/19, the patient reported previously using a fungal cream for one month, which did not improve her toenails. The patient’s provider recommended laser treatments and a fungal cream for the toenails. There is no documentation of contraindications of other medications due to past history of chemotherapy. The patient has requested authorization and coverage for toenail laser treatments.

The patient is a 48-year-old male who was apparently well until approximately two to three years ago when he was found to have low testosterone levels and significant fatigue. He also understands he had an Epstein-Barr virus infection at about the same time and has associated this with the development of his chronic fatigue. The records provided do not address these diagnoses. Some eight months ago, the patient developed a rash on his forearms which developed into what is described as pustular lesions. The patient was initially treated with cephalexin without relief and then with topical silver sulfadiazine with improvement of his symptoms. Additionally, the patient was found to have lesions on his finger nails that were diagnosed as onychomycosis – although they are referred to as splinter hemorrhages in some of the submitted material.

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