Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Burn.
Treatment: Laser therapy (0479T x 1 and 0480T x 1).
The insurer denied coverage for laser therapy (0479T x 1 and 0480T x 1).
The denial is overturned.

According to the documentation submitted this is the case of female with a history of a right-hand injury from a contact burn requiring full thickness skin grafts (FTSG). She presented to the surgeon's office for a follow up. The patient suffered right hand injury from treadmill. The patient presented to discuss scarring, using skin lightening creams over the counter. As noted, the patient was now status post (s/p) hot contact burn requiring split thickness skin grafts (STSG). She is having contractures and restriction to range of motion (ROM) to fingers of the hand on palmar side, plus hyperpigmentation. The patient is right hand dominant and has been using over the counter (OTC) hydroquinone with minimal improvement in color. The plan was to change to 4% (percent) and the patient agreed to Lumenis scar laser care with Kenalog to help control ROM issues. 

Gauglitz noted in "Hypertrophic scarring and keloids following burn injuries" in Up-to-date that "several types of lasers have been used in the treatment of keloids and hypertrophic scars following burn injury, including the fractional CO2 (carbon dioxide laser), pulsed-dye lasers (PDLs), and erbium or neodymium-doped yttrium aluminum garnet (erbium: YAG (yttrium-aluminum-garnet) and Nd (neodymium-doped): YAG) lasers. Laser treatment (particularly fractional ablation type), often in combination with local flap design and/or the application of intralesional agents, is increasingly being advocated and appears to show promise, though efficacy measured by objective parameters varies between studies. Improvements in both clinical and structural features of burn scars have been reported after fractional CO2 laser procedures. In a large prospective study, fractional CO2 laser therapy improved the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments. In another review, patient satisfaction with fractional CO2 laser therapy was 96.7 percent. 

Fractional lasers are also associated with significant surface relief improvements and reductions in scar firmness compared with untreated internal controls. Regardless of these promising results, more in-depth studies are needed to evaluate clinical protocols before definite recommendations for settings and intervals in between treatment sessions can be made." The author noted that for "for widespread hypertrophic burn scars associated with tension that limit function or cause contractures, we suggest surgical scar release and scar excision/revision with adjunctive use of silicone sheeting or gel, or onion extract gel, and pressure therapy. For patients who are not responsive to therapy, we use ablative fractional laser therapy." 

This procedure is FDA (Food and Drug Administration) approved. 

It appears that this patient is a good candidate for this treatment as the patient is limited to be able to use her hand properly because of the burn scar. As noted by
Gauglitz in "Hypertrophic scarring and keloids following burn injuries" in Up-to-date "for widespread hypertrophic burn scars associated with tension that limit function or cause contractures, we suggest surgical scar release and scar excision/revision with adjunctive use of silicone sheeting or gel, or onion extract gel, and pressure therapy. For patients who are not responsive to therapy, we use ablative fractional laser therapy." 

One cannot say that risks are increased over standard therapy which would include scar revision and release (i.e., surgery) as both would require anesthesia with resultant pain. The procedure of ablative laser is painful, and consideration needs to be given to pain management both during and after treatment. In the majority of pediatric cases, general anesthesia is required. 

This procedure is likely to be more beneficial than any other standard treatments or procedures. 

The carrier's denial of laser therapy (0479T x 1 and 0480T x 1) should be overturned.