Rosacea denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 51-year-old male who has a history of rosacea with erythema. He has undergone multiple prior treatment modalities. Per the submitted office notes the patient’s rosacea is primarily telangiectasia type 1. The patient began receiving Intense Pulsed Light (IPL) therapy in July 2005. He has requested reimbursement for the treatments, which the Health Plan denied as experimental/investigational.Although there have been recent reports in the literature touting the efficacy of IPL therapy for facial rejuvenation including treatment of telangiectasia, there is no long-term data substantiating the duration of its effect. The procedure will likely result in only temporary reduction of erythema as laser eradication does not prevent development of additional telangiectasia i.e., recurrence.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for doxycycline for treatment of the enrollee’s rosacea and perioral dermatitis. Findings: The physician reviewer found that rosacea is a common chronic inflammatory disorder of the facial skin characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythematous telangiectatic rosacea and papulopustular rosacea. Individual subtypes are likely a result of different pathogenic factors, thus will respond best to different therapeutic regimens. Rosacea is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photo protection.

Where the denial was upheld

Physician 1: The patient is a 35-year-old male requesting reimbursement for V-beam laser therapy. The patient reports experiencing facial redness and pain. The patient’s provider reports the patient has tried and failed conservative therapy. The patient reports the therapy has been successful and therefore, he has also requested authorization for continued V-beam laser treatments. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.The Health Plan’s denial should be upheld. There is no documentation of prior trial and failure of conservative therapy. Review of the relevant medical literature does not provide any evidence that laser treatment of superficial telangiectasia prevents focal edema and papular and pustular breakouts. Furthermore, this therapy is considered cosmetic in nature.

Findings: The physician reviewer found that the enrollee has requested authorization and coverage for Soolantra (Ivermectin) 1% cream. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s medical condition. A review of the record indicates that the patient has been diagnosed with rosacea. On 11/8/22, the provider noted the patient has previously been treated with pulsed dye laser (PDL) and intense pulsed light (IPL) with little to no improvement. Central facial erythema with telangiectasis was noted. The Health Plan indicates that the requested medication is not medically necessary for the treatment of the patient’s medical condition. At issue is whether Soolantra (Ivermectin) 1% cream is 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 rosacea, then check the rights and deadlines that apply to your plan.