Dermatology Consultation denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: According to the records, the enrollee is requesting consultation with a dermatologist. Internal medicine notes indicate the enrollee has hormonal acne treated with medicated face wash that over-dried her skin and a skin lesion on her face. A referred dermatologist documented jawline inflammatory papules and pustules and scars distributed on her face. Prescribed were Retin-A micro topical gel, spironolactone, and clindamycin 1% lotion. A follow-up visit noted that spironolactone made her nauseous and topical treatment was fine, but she was still having breakouts. Acne was improved, but still present and prescribed was the antibiotic, Doxycycline. On the next visit, her acne was the same, skin was almost clear. Prescribed was Aczone 7.5% topical gel and Retin-A Micro gel was continued.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a dermatology consultation for evaluation of the enrollee’s rosacea. 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 erythemato-telangiectatic rosacea and papular-pustular rosacea. Individual subtypes are likely a result of different pathogenic factors and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a dermatology consultation for evaluation of her changing mole. The physician reviewer found that according to the documentation from the primary care provider’s notes, the patient’s mole in question does not exhibit any concerning signs or symptoms for skin cancer. The patient reports that the mole has been enlarging. She also stated that her mother passed away secondary to skin cancer. However, based on the documentation provided, the requested referral for consultation with a dermatologist is not medically necessary in the absence of any concerning signs or symptoms for skin cancer. Final Result: The reviewer determined that the requested referral is not medically necessary for evaluation of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld.

The parent of a 13-year-old male enrollee has requested authorization and coverage for a consultation with a dermatologist for treatment of the enrollee’s eczema. Findings: The physician reviewer found that based on review of the available records, there is no medical documentation available to support the enrollee’s request for dermatology referral. It is not clear from the medical documentation exactly what condition requires treatment, the body surface area involved, or the prescription therapies that have already been tried and failed in this patient. Without the relevant information, the request for coverage of this referral should be denied, as it is not clear that treatment of the condition lies outside the scope of the primary care physician.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Dermatology Consultationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.