Skin Resurfacing denials: what the review data shows

Where the denial was overturned

Physician 1: The patient is a 53-year-old man with rosacea. He was treated with topical agents without control of telangiectasia. The patient then underwent V-beam laser therapy with improvement. The Health Plan has denied coverage for the laser therapy at issue on the basis it is considered experimental for treatment of the patient’s medical condition. V-beam laser therapy is both safe and efficacious in the treatment of telangiectasia associated with rosacea. This is documented in the Journal of American Academy of Dermatology articles cited above. Furthermore, V-beam laser therapy is standard of care for patients such as this patient. It is not likely the patient would have benefited from topical agents such as MetroGel. Evidence shows that MetroGel is effective for the inflammatory papules of rosacea, not the telangiectasia.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Integra bilayer matrix wound dressing as a component of the enrollee’s debridement and wound vacuum placement procedure to the left foot. Medical literature explain, “First developed for coverage of burn wounds, Integra is a synthetic acellular dermal regeneration template that provides a base for revascularization and neodermal formation. The use of Integra has slowly grown and has now become an important consideration along the reconstructive ladder.” The authors further explain that blood vessels and other cells migrate into the matrix and begin to lay down a new layer of dermis and that the impermeable silicone layer serves to close the wound and prevent fluid egress, concluding that wounds previously thought to have an insufficient vascular bed for grafting, and therefore in need of f…

Where the denial was upheld

Physician 1: The patient is a 35-year-old male requesting reimbursement for V-beam laser therapy. The patient reports experiencing facial redness and pain. The patient’s provider reports the patient has tried and failed conservative therapy. The patient reports the therapy has been successful and therefore, he has also requested authorization for continued V-beam laser treatments. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.The Health Plan’s denial should be upheld. There is no documentation of prior trial and failure of conservative therapy. Review of the relevant medical literature does not provide any evidence that laser treatment of superficial telangiectasia prevents focal edema and papular and pustular breakouts. Furthermore, this therapy is considered cosmetic in nature.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for excision of excess skin and subcutaneous tissue from the patient’s upper arms (brachioplasty) and excision of excess skin and subcutaneous tissue from the abdomen and waist (revision abdominoplasty). Body contouring is potentially medically necessary for treatment of gender dysphoria. Fat transfer for feminizing body shape is most performed as part of body contouring. In this case, the patient has a history of gender dysphoria, facial feminization surgeries, and resultant significant skin laxity and hanging tissue on the arms and abdomen. However, there is a lack of evidence in the literature showing skin removal on the arms and abdomen as an effective treatment for gender dysphoria.

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 Skin Resurfacingwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.