Laser Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for laser therapy for treatment of her medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has had sciatic neuropathy as a complication of hip surgery. The medical records indicate severe axonal injury, with partial recovery over time. Axonal injuries recover slowly, and patients may take years to reach maximal recovery. The medical literature does not show significant benefit from laser treatments in humans with sciatic nerve damage, but animal studies show potential benefit. Human studies of diabetic neuropathy and ulnar neuropathy also show potential for benefit. Given the lack of other effective treatments, the requested laser therapy is medically indicated for the treatment of this patient.

A female enrollee requested laser therapy for medical treatment of her vitiligo. Findings: The physician reviewer found that this patient has a history of vitiligo which has been unresponsive to topical therapies. Based upon the submitted records, the requested laser therapy is medically necessary for the treatment of this patient. In this patient’s case, her condition is abnormal pigmentation related to destruction of melanocytes in the skin. The abnormality is cause by an autoimmune, immunologic process. The requested procedure should correct the pigmentary abnormality, restoring the skin’s natural defense (pigmentation) against ultraviolet-induced skin cancers. All told, the requested laser therapy is reconstructive in nature and is medically necessary for the treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laser therapy (CPT code 17106). Rosacea is a common chronic disorder characterized by periods of exacerbation, remission and possible progression. In rosacea, the non-pharmacologic approach to therapy is adequate skin care, trigger avoidance, and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. Further, the US Food and Drug Administration (FDA) has approved treatments include topical metronidazole and azelaic acid. Laser treatment can be used in combination with medical and topical treatments. Since this patient has failed many standard treatments, a multifaceted approach to therapy that includes laser treatment was an appropriate treatment option.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for direct manipulation techniques, such as compression, trigger point pressure release, deep massage, spray and stretch, ultrasound transverse friction massage and/or laser therapy. Current evidence-based literature regarding the management of hypermobile Ehlers-Danlos syndrome and myofascial pain syndrome is limited in size and quality. A few studies have shown positive effects with physiotherapy. While the optimal rehabilitation program has not been identified, research supports that proprioception, strength, and motor control, in addition to education, physical activity, and fitness are important components.

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