Scar Revision denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s scar after removal of basal cell carcinoma.The submitted documentation supports the medical necessity of scar revision. Skin cancer is the most common of all cancers. Mohs surgery is an effective technique for removing common types of skin cancer. A successful reconstruction mimics the premorbid state and maintains function. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue, with good contour the aesthetic endpoint.

A 54-year-old female enrollee requested scar revision of the left abdomen and fat transfer into the left abdomen for medical treatment of her late effect of surgery, painful lesion and scar condition. Findings: The physician reviewer found that the patient has complications related to performance of a medically necessary procedure. This is producing a functional deficit that has failed conservative management. Thus, reasonable treatments aimed at correcting complications related to a medically necessary procedure should be considered medically necessary as well. The patient has failed conservative management and has an abnormal appearance. This is not cosmetic surgery, as cosmetic surgery is aimed at improvement of normal structures, not abnormal ones. In sum, the patient has complications related to a medically necessary procedure and she has failed typical conservative management.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The submitted documentation does not support that the requested services are medically necessary. The literature supports that in the case of hypertrophic scarring, the timing of surgical treatment is an important consideration in the treatment protocol of scar revision strategy. Hypertrophic scars may mature over at least a one-year period and can show significant flattening and softening without any physical manipulation. In this case, the patient has scar hypertrophy in the lateral breast scars six months after reduction mammoplasty. There is no indication for early excision of hypertrophic scars to prevent further hypertrophy. There has been an insufficient amount of time for scar softening to occur.

The patient is a 56 year old male that underwent surgical closure of a skin cancer defect in January 2006. He requested a scar revision almost immediately following surgery. Photographs dated May 2006 show a well-healed flap with obliteration of the upper part of the nasojugal fold. At issue is whether surgical scar revision is medically necessary for treatment of the patient’s condition.Scar revision is not medically necessary for this patient. His flap has healed well and the records do not document any problems with infection, pain or persistent edema. The submitted photographs show a healed flap without significant scarring or edema. The nasojugal fold is indistinct in the area of the flap, but the patient is only five-months postoperative, and this contour may improve in time.

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