Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for laser hair removal due to pain. The health plan denied the request indicating the request was a cosmetic surgery and not medically necessary for treatment of pseudofolliculitis barbae.At issue in this case is whether the requested laser hair removal is medically necessary for treatment of the patients medical condition. Does the alleged abnormality constitute an abnormal structure of the body caused by any of the following: congenital defects; developmental abnormalities; trauma; infection; tumors; disease? Is the requested procedure performed to improve function or create a normal appearance to the extent possible? Does the procedure provide more than a minimal improvement in the appearance of the patient? If the above factors are met, the procedure must be provided under the expanded concept of medically necessary reconstructive surgery/procedure.Pseudofolliculitis barbae is a relatively common disorder that occurs in glabrous skin with coarse, curly hairs. It is a frequent disorder of any hair-bearing skin with thick, curly hairs that are removed repetitively by shaving, waxing, or plucking. Shaving is a predisposing factor because it results in a sharp, pointed, short hair that may curl over and reenter the skin. Extra-follicular penetration of the hair shaft is one cause of pseudofolliculitis barbae. Trans-follicular penetration of the hair shaft may occur as well. The primary lesions of pseudofolliculitis are erythematous papules and pustules. When chronic inflammation is present, hyperpigmentation, hypopigmentation, and fibrotic scarring may accompany the clinical picture. Biopsy results show foreign body giant cells in the dermis with micro-abscess formation. Cultures of the pustules are sterile, and bacteria are therefore not implicated in the pathogenesis of this disorder.Treatment modalities used for pseudofolliculitis barbae have been largely disappointing, and include topical tretinoin cream; corticosteroids; topical and oral antibiotics; surgical depilation; electrolysis; and tedious shaving regimens. The only definitive cure for pseudofolliculitis barbae is permanent removal of the hair follicles. Surgical depilation carries a high morbidity. Electrolysis is a laborious procedure, and incomplete follicular destruction has resulted in keratin granulomas and pseudofolliculitis barbae. Selective follicular damage or destruction has been demonstrated with a variety of laser systems including ruby lasers; diode lasers; alexandrite lasers; neodymium-doped yttrium aluminum garnet (ND:YAG) laser; and a pulsed non-coherent light source. Although all of these systems have been shown to be effective in delaying hair regrowth, recent studies have demonstrated that some pulsed laser and light-source hair-removal systems are capable of producing a permanent reduction in hair density in the treated areas. In this case, the requested treatment is reconstructive and may lead to a cure. Therefore, the requested treatment is medically necessary.Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.