Botox Argumentative Essay

A review of the records reveals the member to be an adult male with a birth date of 11/06/1995. The member has a diagnosis of hyperhidrosis. The member’s treating provider, Michael Shelling, MD recommended the member undergo treatment with Botulinum injections into the axillae.

The carrier has denied coverage of Botulinum injections into the axillae as not medically necessary. There is a letter from the carrier to the member dated 06/02/2016 which states in part:

“The specific reason for the denial of your appeal for Botox is that requested documentation was not received. Without medical documentation, the appropriate criteria cannot be applied to determine medical necessity.”

There is a letter from Michael Shelling, MD dated 06/03/2016,
Jordan Epstien. He has been seen previously for recurrent skin infections and abscesses. He was seen on 6/1/16 for evaluation of several skin concerns, but he was most concerned about his severe refractory axillary hyperhidrosis. It is not responsive to antiperspirants and he has failed previous trials of aluminum chloride. He is not a good candidate for oral therapies at this point due to the potential side effects. He suffers from severe sweating which is associated with maceration of this tissue and occasional skin infections. Unfortunately, this issue causes him significant social distress as well, so I feel he is really an excellent candidate for direct treatment with botulinum toxin injections in the axilliae.”

Final External Review Decision:

The carrier’s decision in denying coverage for the requested Botulinum injections (L74.510) was appropriate.

The requested Botulinum injections (L74.510) are not medically necessary for the treatment of this member’s condition.

The previous denial should be upheld.

Findings:

The member is a 20-year-old male with axillary hyperhidrosis. The member also has a history of hidradenitis suppurativa. The member’s treating provider states that the member has tried and failed treatment with topical aluminum chloride and systemic anticholinergics have been avoided due to the side effect profile. According to the member’s treating provider, the member has maceration of the skin. Therefore,
The member’s treating provider has avoided the use of systemic therapies due to the side effect profile. However, the member has no true medical “contraindication” to a trial of systemic therapy. The member’s treating provider states that the member has had skin maceration/infection, but this he has a comorbidity of hidradenitis suppurativa. It is not clear if the maceration/infection was secondary to the hyperhidrosis or the hidradenitis suppurativa.

Hidradenitis suppurativa commonly affects the axillary vault as well as the inguinal region. It is also not clear from the medical records what parameters have been used to diagnose maceration due to the hyperhidrosis versus maceration and skin infections caused by the hidradenitis suppurativa. Given this member’s clinical circumstances as well as application of the policy that is in effect, medical necessity for Botox injections for this member has not been established.

Therefore, the carrier’s decision in denying coverage for the requested Botulinum injections (L74.510) was