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

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 patients 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. 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 2: The patient is a 53-year-old male with a diagnosis of rosacea characterized by telangiectasia. There is no evidence in the submitted medical records of other rosacea features. The patient underwent V-beam laser treatment for telangiectasia. The Health Plan has denied coverage for the laser therapy at issue on the basis that there is insufficient evidence in the peer-reviewed literature establishing the safety and efficacy of V-beam laser therapy for treatment of telangiectasia. It is not unusual for facial telangiectasia to fail to respond to topical metronidazole preparations or oral antibiotics, which are mainstays of rosacea treatment. Facial telangiectasia may also arise as a result of photo damage and in this case other stigmata to suggest rosacea were not documented. Furthermore, the submitted evidence demonstrates the patients condition failed to respond to treatment with MetroGel, but did improve with laser therapy. 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 53-year-old male who was noted on 7/30/03 to have superficial facial veins consistent with rosacea. He was then treated with MetroGel and sunscreen. The patient subsequently received two V-beam laser treatments to the face in September and December 2003.  He was noted to have improvement of the redness and blood vessels on the face after the first treatment. The patient has requested reimbursement for the laser treatments at issue. The Health Plan has denied the patients request on the basis that V-beam laser therapy is considered investigational for treatment of telangiectasia. As delineated in the review article on rosacea from the Journal of the American Academy of Dermatology, there are many different variants of rosacea and many different theories as to the etiology of the disorder. Based on the description of this patients physical findings, he most likely had predominantly the erythematotelangiectatic form of rosacea. Though the patient failed therapy with MetroGel, it does not appear other therapies were tried prior to use of the V-beam laser. As the above referenced article indicates, there are many treatments that have been demonstrated to reduce facial erythema in rosacea including sodium sulfacetamide and sulfur, azelaic acid, topical tacrolimus, tretinoin, oral antibiotics, isotretinoin and various other medications. While there is evidence that vascular lasers may be useful for the telangiectatic component of rosacea, long-term studies are needed to determine whether dermal and vascular remodeling with laser therapy generate lasting remission in rosacea. To date, there is insufficient data demonstrating that laser therapy is superior to other therapies in providing long-lasting remission of rosacea. Furthermore, it appears this patient did not exhaust standard therapies prior to resorting to laser therapy. 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.