Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for reconstructive surgery to the back for a closed wound caused by melanoma excision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees melanoma.At issue in this case is whether the requested reconstructive surgery to the back to repair a wound; caused by melanoma excision, is medically necessary to treat the patients medical condition? Does the alleged abnormality constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital defects; developmental abnormalities; trauma; infection; tumors; or disease. Is the requested surgery performed to do either of the following: improve function or to create a normal appearance to the extent possible? Does the surgery provide more than a minimal improvement in the appearance of the patient?  A study note that scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised; depressed; wide; or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. The patient has a large right upper back scar as the result of previous melanoma resection.  The initial resection was complicated by a large dehiscence that required an extended time to heal by secondary intention.  The photograph of the resulting scarring should be considered a significantly abnormal result that would not be generally expected.  There is a significant contour depression, and the size of the scar is much greater than what would be expected.  Scars on the back, especially after a large melanoma resection, can be unfavorable.  But this appearance is outside the normal range.  The complication experienced by this patient is the likely reason that the resulting scar is outside the normal range.  The plastic surgery plan to serially excise the scar is a reasonable option to decrease the size of this large scar and approach a relatively normal scar.  The patient did suffer from a significant complication that led to a resulting scar that is significantly outside a normal range of expected scarring.  Reconstructive surgery can be done to approximate a relatively normal appearance.  Abnormal scarring following melanoma resection is an abnormal structure of the body. This is the direct result of the complication suffered by the patient following her melanoma resection. There is no functional impairment that is present, but the plan by the plastic surgeon is to create a more normal appearance of the scar.  More than a minimal improvement would be expected following serial scar resection and closure. Thus, the plastic surgery plan to serially resect this scar should be considered reconstructive surgery. Therefore, the requested procedure 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 overturned.Credentials/Qualifications: The reviewer is board certified in plastic surgery 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.