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

Physician 1:  The patient is a 51-year-old male who has a history of rosacea with erythema. He has undergone multiple prior treatment modalities. Per the submitted office notes the patients rosacea is primarily telangiectasia type 1. The patient began receiving Intense Pulsed Light (IPL) therapy in July 2005. He has requested reimbursement for the treatments, which the Health Plan denied as experimental/investigational.Although there have been recent reports in the literature touting the efficacy of IPL therapy for facial rejuvenation including treatment of telangiectasia, there is no long-term data substantiating the duration of its effect. The procedure will likely result in only temporary reduction of erythema as laser eradication does not prevent development of additional telangiectasia i.e., recurrence.  IPL therapy treats the telangiectatic (prominent blood vessels) features of rosacea and these do not impact the health status of the patient. 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 51-year-old male with a history of severe rosacea. He was tried on Metrogel, Loprox TS, Finacea, Allegra, clonidine hydrochloride, Rosanil, Periostat, Clindets, Avar Green cream, Avar cleanser, Plexion and Elocon without good results. In July 2005 the patient being receiving Intense Pulsed Light (IPL) therapy with observed improvement. At issue is whether IPL therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.The American Academy of Dermatology (AAD) describes IPL as an acceptable treatment for rosacea. In addition, the American Society of Laser Surgery and Medicine also recognizes IPL as standard treatment for rosacea. Furthermore, the submitted clinical information indicates the patients condition was unresponsive to standard therapies and was severe enough to warrant treatment in this case. Therefore, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 51-year-old man who has rosacea with severe, disabling flushing. This interferes with his livelihood because he is a schoolteacher and is continually in front of children and parents. All the usual topical and systemic medications for rosacea have been ineffective. Intense Pulsed Light therapy has resulted in a significant decrease in the patients signs and symptoms. The Health Plan has denied coverage for Intense Pulsed Light therapy indicating it is considered investigational.Intense Pulsed Light therapy is accepted by the medical community as medically appropriate treatment for the flushing of rosacea. In this particular patients case, it is medically reasonable and indicated because the patients symptoms are medically significant and interfere with his normal functioning. Furthermore, the patients previous attempts at therapy were unsuccessful whereas Intense Pulsed Light therapy has been effective for him. Therefore, I have determined that the therapy at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.