Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

enrollee has requested authorization and coverage for Infini laser treatments. Infini radiofrequency microneedling laser system delivers controlled radiofrequency energy to break down scars to deep skin layers. This bipolar radiofrequency system generates fractional zones of electrothermal damage deep in the dermis, surrounded by areas of undamaged tissue under a more-or-less intact epidermis. These areas of damage in the dermal matrix induced a vigorous wound healing process supported by the surrounding undamaged tissue and lead to the synthesis of new collagen and elastin, dermal remodeling and replenishment of hyaluronic acid. Microneedle fractional radiofrequency also showed improvement of acne scars and large facial pores with less adverse events than fractional lasers. In a study, 20 patients were treated with Infini lasers for atrophic, burn, photoaging and acne scars. Patients were examined one month after the last session. Efficacy and patients satisfaction were assessed using a ten-point score. Efficacy was also evaluated by a physician on a ten-point score, measuring global improvement on skin texture, depending on the condition treated. The mean satisfaction of treated patients was very high. The balance between efficacy and a well-tolerated procedure was highly favorable. No infectious complication was reported despite the absence of antibiotic and antiviral treatment. It was concluded that the treatment is efficacious in treating atrophic skin scars, with the advantages of minimal post-treatment effects and very high patient satisfaction.There are two questions addressed in this case: (1) Does the requested Infini treatment satisfy Californias criteria for reconstructive surgery?(2) Is the requested Infini treatment medically necessary for treatment of the patients condition?Per Health and Safety Code Section 1367.63, health plans in California must cover reconstructive surgery. Reconstructive surgery is defined as surgery performed to correct or repair an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The surgery must be requested to either improve function or to create a normal appearance (to the extent possible). If the surgery is being requested to create a normal appearance, then the surgery must offer more than a minimal improvement in the appearance of the patient.Here, the patient was noted to have an abnormal structure in the face (scarring, redness). The abnormal structure was caused by disease (systemic lupus erythematosus). The procedure is being requested to create a normal appearance (to the extent possible). Recent studies suggest the Infini laser treatment can offer more than minimal improvement. Therefore, California criteria for reconstructive surgery have been met. Additionally, there are no other standard treatments that are more likely to improve the patients facial redness and scarring. Clinical evidence suggests that this treatment is efficacious in the treatment of this patients condition. Therefore, the requested services are also medically necessary.