Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scar deformity
Treatment: Reconstruction Surgery To Restore or Improve Body Function (13101, 13102 and 15002)
The insurer denied: Reconstruction Surgery To Restore or Improve Body Function (13101, 13102 and 15002)
The denial is upheld.

The patient is an adult female. She had multiple previous surgeries of the lower extremities and buttocks related to deformities after massive weight loss and previous scar revision surgery. She developed suture line dehiscence of the buttock and thigh scars, which healed with a tethered scar deformity, limiting her ability to wear clothes comfortably related to pain on these areas of unstable scar. She also had scarring of the anterior thighs related to previous surgical procedures which produced a tethering of the anterior lower thigh skin and difficulty with ambulation. She had previous breast surgery with left medial breast suture line dehiscence resulting in an asymmetric contour and discomfort fitting into a bra. The patient underwent scar revision of the bilateral buttocks and inner thighs, scar revision of the bilateral anterior thighs, and scar revision of the left medial breast 6 months ago. Because of the complications and unfavorable scars that developed after her previous medically indicated procedures, scar revision was performed to mitigate the chronic pain and discomfort resultant from the poor scarring.

The requested health service is not medically necessary.

Per the MCG (Milliman Care Guidelines) guidelines, 27th Edition, "Scar Revision": Scar revision may be indicated for ALL of the following:
Scar present for 1 year or more:
Scar causes signs or symptoms, as indicated by 1 or more of the following:
Loss of range of motion of joint
Pain
Signs or symptoms persist despite medical treatment, including 1 or more of the following:
5-Fluorouracil injection
Bleomycin injection
Corticosteroid injection
Cryotherapy
Laser therapy
Radiation therapy
Silicone products (cream, gel, gel sheeting)
In this patient's case, measured objective loss of range of motion, pain requiring analgesics, or any conservative therapies are not documented in the provided records. The MCG (Milliman Care Guidelines) are not met.
Scars can have multiple causes, and depending on the previous healing, can result in a hypertrophic scar or keloid. They can vary in quality depending on the individual's racial characteristics, the mechanism of the trauma, and conditions in which the wound healed. As stated in a review on scarring by Thomas et al., There are many treatments described for symptomatic scarring. In a recent review article by Khansa et al., standard treatments for hypertrophic scarring are described: silicone sheeting, intralesional corticosteroids, 5-fluorouracil, bleomycin, and scar massage. These aforementioned therapies are all non-operative scar treatments. Further, in another review by Berman et al., they state that numerous conservative symptomatic scar treatment therapies can be used with success. Evidence supports silicone sheeting, pressure dressings, and corticosteroid injections as first-line treatments. When first-line treatments for keloids and hypertrophic scars fail, combination therapy (surgery, silicone sheeting, and corticosteroid injections) is an effective second-line option.
In order to establish medical necessity of a scar, confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence or a history of frequent physician visits for scar-related symptoms are necessary to support the history provided by the plastic surgeon. The records do not provide sufficient documentation that supports a functional need for a scar revision. Further, the records do not confirm that the scar have been allowed to mature for the 12-18-month postoperative period where scars improve significantly.