Laser Hair Removal denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for laser hair removal due to pain. The health plan denied the request indicating the request was a cosmetic surgery and not medically necessary for treatment of pseudofolliculitis barbae.At issue in this case is whether the requested laser hair removal is medically necessary for treatment of the patient’s medical condition. Does the alleged abnormality constitute an abnormal structure of the body caused by any of the following: congenital defects; developmental abnormalities; trauma; infection; tumors; disease? Is the requested procedure performed to improve function or create a normal appearance to the extent possible? Does the procedure provide more than a minimal improvement in the appearance of the patient?

The patient had a history of gender dysphoria and has been treated with cross-gender hormone therapy since 2016. The submitted documentation indicates that patient’s facial hair limits her ability to be perceived and negates her gender identity. The patient reports being constantly mis-gendered due to the presence of facial hair, which exacerbates her symptoms of gender dysphoria. The documentation also indicates the patient has had both electrolysis and laser treatment in the past without side effects. A referral was made to dermatology for laser hair removal for gender dysphoria. A dermatology consultation on 11/2/18 revealed the patient was assessed for laser hair removal as part of treatment for gender dysphoria. The patient would like the facial hair treated; otherwise, she otherwise has to shave daily.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for laser hair removal. Treatment of pilonidal sinuses can be challenging as there are multiple modalities and options with varying rates of success and support in the current medical literature. The American Society of Colon and Rectal Surgeons’ clinical practice guidelines for the management of pilonidal disease provide a comprehensive summary of many treatment modalities for pilonidal sinuses. In particular, elimination of hair from the gluteal cleft and surrounding skin by shaving or laser removal is given a weak recommendation based on low quality evidence, and the guidelines do not include evidence that one modality, laser removal, is better than the other, shaving.

The enrollee’s parent is requesting authorization and coverage for laser hair removal for a history of pilonidal disease, status post incision and drainage. The records indicate the enrollee underwent a procedure of incision and drainage (I&D) for an eight centimeter abscess, and an antibiotic course of Ancef. A follow up visit indicated the wound was closed and education was provided including possibility of elective pilonidal cyst excision in the future, good hygiene and hair removal with waxing, Nair or laser hair removal. Follow up at the surgery clinic indicated drainage from the incision site was clear but a 10 day course of antibiotic was prescribed for prophylaxis, and aggressive hygiene and hair removal was advised. At a subsequent follow-up visit, there was no longer any drainage or pain at the incision site and instructions were to return to the clinic as needed.

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 Laser Hair Removal, then check the rights and deadlines that apply to your plan.