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

Physician 1:  The patient is a 58-year-old female with an asymptomatic pterygium in the left eye. She was referred to an ocular surgeon for evaluation and excision of the lesion. The specialist recommended reconstruction of the ocular surface with an amniotic graft after excision, and a request for authorization was submitted to the Health Plan. The Health Plan considers this an investigational procedure and authorization was denied.There is no peer-reviewed evidence that pterygium excision with amniotic membrane transplantation is superior to any currently recognized surgical modalities. Although amniotic membrane graft is a recognized and accepted procedure, it has not yet become the standard of care.  In a fairly routine situation such as this one, a more established surgical technique offers the best outcome for the patient. As such, I have determined that the requested procedure is 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 58-year-old female with a pterygium in the left eye. This appears to be a primary occurrence and she is currently asymptomatic. The patient has consulted with an ocular specialist, and a recommendation was made for pterygium excision with amniotic membrane transplantation. The Health Plan has determined that the use of amniotic membrane transplantation is an experimental/investigational approach, and has therefore denied coverage for the procedure.  The present standard of care for pterygium excision requires that tissue coverage be provided for the area of the conjunctiva where the resection occurred. The risk of rejection or failure is much lower if the patients own tissue is used; conjunctival autograft is a common approach. Amniotic membrane is generally used when it is not possible to harvest enough of the patients own healthy tissue due to inadequate or injured conjunctiva. There is no evidence of any condition that precludes conjunctival autograft or that would support the need for a more innovative and less proven surgical intervention. Therefore, I have determined that the requested procedure is 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 58-year-old female who has a primary pterygium, which is not encroaching on the pupil. There is no indication that this is a recurrence of a previous lesion or that there is scarring involved. The patient has requested authorization for pterygium excision with amniotic membrane transplantation. Her request was denied by the Health Plan, citing the investigational nature of the procedure.There are several techniques currently in use for pterygium surgery that are associated with decreased rates of recurrence. The most widely utilized procedure is conjunctival autografting and the ancillary use of topical mitomycin is also relatively common. Amniotic membrane grafting however, is still very new as a surgical modality in pterygium surgery and its efficacy in the prevention of recurrence has not yet been proven. The application of this procedure is clearly not the standard of care. There have been very few peer-review articles related to this technique and none have demonstrated its superiority over standard treatment modalities. On the contrary, in the journal article citied above the amniotic graft was shown to be inferior to conjunctival allograft and other standard procedures.Based upon the information set forth above, I have determined that the requested procedure is 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.