Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Melanoma of the right anterior lower leg
Treatment: Durable medical equipment; a suction pump ("wound VAC")
The insurer denied coverage for: Durable medical equipment; a suction pump ("wound VAC")
The denial is: Overturned
 
This is an adult who presented with a new diagnosis of melanoma of the right anterior lower leg. The patient's twin brother and father had melanoma. The patient is participating in the stage II neoadjuvant trial. Computed tomography (CT) showed 2 small lung nodules. The patient had a biopsy of the right anterior lower leg with at least a 2.5 millimeter (mm), ulcerated 4 mm squared(2) lesion noted. The patient received neoadjuvant chemotherapy. The provider noted that due to the location of the primary site he anticipated the patient would need skin grafting. The provider will engage plastic surgery and coordinate the reconstruction. The plan was for wide excision of the right anterior lower leg with sentinel lymph node biopsy, and Integra placement. The provider noted that he will order a wound vac. A wound vac was ordered for placement on the right pretibial area following local excision of melanoma. The wound vac would be initiated allowing for delayed grafting.
The patient underwent wide local excision. Sentinel node biopsy was positive for metastatic melanoma. The skin, right pretibial area was positive for Cark level VI, Breslow thickness 4.3 millimeter (mm) adjacent to prior biopsy site with a microsatellite. The skin area excised was 3.5 x 3.3 centimeters (cm) in size.
The patient was seen post operatively for a wound vac check. On exam, there was good integration of the underlying Integra. The plan was split-thickness skin graft (STSG) next week. In terms of wound care the plan was for dry Tefla daily.
The patient returned for post-operative visit. It was noted that an enlarging seroma in the right groin was becoming more painful and it was aspirated. The right calf surgical wound was without redness, swelling, or drainage. There was good integration of the underlying Integra. The plan was for STSG.
The patient was seen again with the plan for split-thickness skin graft (STSG) right thigh to right shin with wound vac placed over the right shin wound perioperatively. The right inguinal seroma recurred and was drained again.
The patient underwent STSG and incision and drainage (I & D) of right groin lymphocele. The patient returned for a follow-up visit. The wound vac was removed, and it was noted that there was healthy appearing STSG without areas of ischemia. 
The patient returned where it was noted there was an 80% take of the STSG to the right pretibial area. The drain from the right groin was removed.
The patient returned and was now noted to have a 50% take of the STSG to the right pretibial area.
The patient returned where it was noted that a new pigmented lesion appeared along the periphery of the graft and punch biopsy of this lesion was done.
This patient had a melanoma resected in the pretibial area. The provider placed an Integra graft to facilitate healing until a split-thickness skin graft (STSG) would be placed. In the meantime, a wound vac was placed over this area to facilitate the ingrowth of the Integra. A STSG was placed subsequently. Thus, in this case the wound vac was medically necessary, especially in this difficult area of the body where it is difficult to achieve wound healing. An Integra was placed as a dermal substitute until a STSG could be placed.
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for durable medical equipment; a suction pump ("wound VAC") is substantiated.