Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 44-year-old male with long-standing acne vulgaris.  He has been treated with multiple medications, both topical and oral, with only limited improvement. The patient underwent several Blu-light phototherapy sessions, a light based technology, to clear his acne and is now requesting reimbursement for the cost of the therapy.  The Health Plan denied reimbursement citing the investigational nature of Blu-light phototherapy.At this time, the light therapies are an unproven treatment approach and there is very limited data comparing their efficacy with traditional acne therapies.  A review of available research identified only one study in which the investigator was sponsored by the light source company.  To date, there is no compelling evidence that the light-based therapies are likely to result in superior treatment outcomes. Therefore, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 44-year-old male who reports having had extensive acne for at least 20 years. Treatments with numerous oral antibiotics and standard topical medications have been unsuccessful. Blu-light phototherapy was administered from November 2005 through April 2006, which resulted in almost complete clearing according to the patient.  He is now seeking reimbursement for the therapy.  The Health Plan determined Blu-light phototherapy was experimental/investigational and denied his request.Blu-light phototherapy is no longer considered experimental or investigational. It is approved by the FDA and is considered medically appropriate in the treatment of acne.  In this instance, standard therapies were tried and did not effectively remedy the patients condition. Blu-light phototherapy however, was extremely effective and resulted in almost complete clearing of his skin.  Clearly, Blu-light phototherapy was medically essential for this patient.Based upon the information set forth above, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 44-year-old male with long-standing acne. According to his dermatologist, multiple systemic and topical medications have been prescribed that were either ineffective or not tolerated. The patients provider described mild acne to chin in the October 2005 progress note and noted scarce lesions in the November 2005 progress note.   There is no indication the patient was taking any medications in November 2005 or that previous treatment attempts included Accutane.  The patient elected to proceed with Blu-light phototherapy and has submitted a request for reimbursement.  The Health Plan considers this an investigational therapy and has denied coverage and reimbursement.The skin descriptions included in the record from the patients provider suggest a mild degree of acne.  Additionally, it does not appear that all of the standard options for medical management of his condition had been exhausted.  Specifically, it was noted in the record that Accutane had not been prescribed.  Based on these considerations, I have determined that the therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.