Dermatology Referral denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a referral to a dermatologist. A review of the provided records indicates that the patient was evaluated during an in-person visit resulting in a diagnosis of eczema herpeticum. Follow-up was by telephone. The provider recommended referral to dermatology since the patient’s known atopic dermatitis was not responding to the therapies provided. On the most recent visit, the patient was to start on clindamycin phosphate for atopic dermatitis, which is inconsistent with the treatment recommendations for patients in this clinical setting. In addition, adequate management of a complex dermatological condition such as atopic dermatitis requires in-person consultation to be appropriately examined.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatologist referral for evaluation of the enrollee who presented with a suspicious mole. Findings: The physician reviewer found that the request for coverage of dermatology referral should be approved. The size of the area is estimated at 2.5 cm. Dermatologists have specialized training in the evaluation of nevi and other skin growths. The medical literature shows that dermatologists are able to detect thinner lesions and are able to detect them at an earlier stage than those melanomas diagnosed by other physicians. Additionally, there is a family history of skin cancer, and the primary care provider recommended an evaluation by a dermatologist.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a referral to a board-certified dermatologist who treats Mast Cell Activation Syndrome (MCAS).Mast cell activation syndrome refers to the clinical presentation of symptoms due to mast cell-mediated release. The diagnosis of MCAS requires that several criteria be met to confirm a diagnosis of MCAS. The first criterion requires episodic, objective signs and symptoms consistent with MCAS involving at least two organ systems. Subjective symptoms alone, such as fatigue and difficulty concentrating, in the absence of signs and symptoms in two other organ systems, do not warrant an evaluation for mast cell disorders. In addition, evidence of systemic mast cell-mediator release, corresponding temporally to the presence of symptoms with tryptase the most specific for mast cell activation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dermatology referral. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s hypertrophic skin disorder.At issue in this case is whether the requested dermatology referral is medically necessary for treatment of the patient’s medical condition.Individuals may acquire a multitude of benign skin lesions over the course of a lifetime. Many of these lesions are easily visible, and patients often ask clinicians to confirm that new growths on the skin are benign. Most benign skin lesions are diagnosed on the basis of clinical appearance and history.

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