Diagnosis: Basal Cell Carcinoma of the forehead

Treatment: Levulan SOL (solution)

The insurer denied coverage for Levulan SOL

The denial is upheld.

The patient is a female with Basal Cell Carcinoma of the forehead that was biopsied. The patient was successfully treated with Mohs surgery for the basal cell carcinoma of the forehead with closure by advancement flap and clear margins by Mohs micrographic surgery. The requested medication was Levulan solution for photodynamic therapy.

Based on the submitted documentation Levulan is not medically necessary. The patient has a history of basal cell carcinoma which was treated with Mohs surgery and advancement flap closure. The basal cell carcinoma has been treated definitively and does not require further therapy based on the standard of care. It is noted that the patient has a prior history of actinic keratoses which were treated with liquid nitrogen. Documentation detailing the necessity for photodynamic therapy with Levulan solution is not provided. Based on the provided documentation, Levulan solution is not medically necessary for a basal cell carcinoma which has been successfully treated with Mohs micrographic surgery with clear margins. The decision is thus upheld based on the standard of care and the submitted medical documentation.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Levulan SOL is upheld. Medical Necessity is not substantiated.