Vitiligo denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for exome sequencing testing (CPT 81415). The provider caring for this patient has recommended whole exome sequencing (WES) for diagnostic purposes given the constellation of symptoms including enamel hypoplasia, eczema, vitiligo, xerosis, and skin hypopigmentation. In contrast to current sequencing tests that analyze one gene or small groups of related genes, WES will analyze the exons or coding regions of over 20,000 genes. Therefore, sequencing the exome is an effective method of analyzing the patient’s DNA to discover the genetic cause of diseases or disabilities.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for excimer laser treatments. Vitiligo is an autoimmune, chronic skin condition characterized by the loss of pigment-producing melanocytes resulting in depigmented patches. These patches are asymptomatic but can cause significant psychological and emotional effects. Depending on the body surface area affected, multiple treatment options are available. For limited patches, defined as less than 10% body surface area, treatment options include topical high potency steroids, topical calcineurin inhibitors, topical Janus kinase inhibitors, and narrowband ultraviolet B (NBUVB), with or without adjunctive therapies.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested dermatology and related services on an emergent or urgent basis. Findings: The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not believe he was experiencing an emergency medical condition on the dates in dispute. Based on the records provided the patient’s presentation on the dates in dispute was not consistent with the above definition of an emergency medical condition. The patient presented for evaluation and treatment of psoriasis and vitiligo. Psoriasis is a chronic disease that can be associated with flares and remissions.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Excimer laser therapy. Vitiligo is an inflammatory disease that requires medical treatment. There are several treatment options available including topical creams, such as Opzelura, and light-based therapy including narrowband (NB) ultraviolet (UV) treatment and laser therapy. In this case, the patient has a diagnosis of vitiligo. The records indicate that the patient reported that NBUVB therapy and Excimer laser therapy were helpful. In clinic notes, the patient reported improvement with the use of Opzelura topical cream to his hands. There is a lack of data in current medical literature regarding the combination of the two treatments, Opzelura and Excimer laser therapy. The provider recommended the continuation of Opzelura, which is approved by the U.S.

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