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VALLEY CARE IPA

DEPARTMENT: Health Services – Authorization Department REFERRAL GUIDELINE: Guidelines for Primary Care Physicians PREPARED BY: L Shockley, RN; R. Lynn, MD EFF. DATE: 4/2016 REVISION DATE(s): 9/16, 6/19 APP. BY: UM Committee

Problem PCP Responsibility Indication for referral Refer To Recommended Treatment Referral can be certified for the following:

1) Topical medication including but not limited to Benzoyl 1) There has been no significant clinical In panel Dermatologist Peroxide, Antibiotics (i.e., Cleocin T, Erythromycin) and improvement after eight weeks of Retin A. treatment. 2) Oral antibiotics (i.e., Tetracycline, Erythromycin, 2) Acne Fulminans Doxycycline, Minocin) and exercise caution in females on birth control pills. If one 4-week course of antibiotics is unsuccessful then an alternative antibiotic should be used for a second 4-week course. 3) Severe nodulocystic acne unresponsive to above treatment modalities will require oral antibiotic in conjunction with topical treatment x 8 weeks.

(Utilize two modalities in conjunction (i.e., oral and/or topical) for an 8-week period of time. Recommended Treatment: Referral can be certified for the following: In-panel Dermatologist

Whether single or multiple lesions: 1) Failure of single or multiple lesions to respond to two treatments by the PCP. 1) Actinic Keratosis may be treated by the PCP with Liquid 2) If PCP does not stock liquid nitrogen. Nitrogen. If the lesion(s) has not resolved one month after treatment but is significantly smaller, can repeat Liquid Nitrogen. If there is no improvement one month after treatment, then should or use alternative treatment approach. 2) Another alternative treatment for Actinic Keratosis is to spot treat with Fluroplex or 5% Efudex Cream applied BID for 2-4 weeks and then allow to heal for 8 weeks.

Page 1 of 5 \\10.2.1.7\data\Quality-Internal\Policies & Procedures\UM Guidelines\VC\Dermatology Guidelines for Primary Care Physicians.doc 06/05/19 Problem PCP Responsibility Indication for referral Refer To ATYPICAL LESIONS Recommended Treatment: Referral can be certified for the following: In-panel Dermatologist

1) Biopsy, except in difficult anatomical locations (i.e., nose, 1) If Pathology reveals Basal Cell ears, eyelids). Carcinoma, 2) Biopsy is required for an exact Pathological diagnosis or any other pathologically atypical which dictates if further definitive treatment is required. lesion that required definitive treatment. (recommend excision biopsy of pigmented lesions) COMMON SKIN Diagnose/Treat the following with standard therapeutic Referral can be certified for the following: In-panel Dermatologist /PROBLEMS modalities for 4-6 weeks: 1) Problem in diagnosis. 1) Dermatophytosis/Tinea 2) Unresponsive for 4-6 weeks of standard 2) Herpes Zoster treatment 3) Seborrhea 4) Tinea Vericolor 5) 6) 7) 8) Pediculosis 9) Drug Eruptions 10) Minor Burns 11) Insect Bites 12) Condyloma Acuminata 13) Burns 14) Canker Sores 15) /Carbuncles 16) Molluscum Contagiorium DERMATITIS/ECZEMA Recommended Treatment (must perform all within 4-6 Referral can be certified for the following: In panel Dermatologist week period of time): or in panel Allergist No improvement within six weeks of all 1) Topical corticosteroid appropriate to anatomical area of treatments listed. involvement. 2) Moisturizer 3) Avoid excessive bathing/washing and deodorant/antibacterial soaps.

Page 2 of 5 \\10.2.1.7\data\Quality-Internal\Policies & Procedures\UM Guidelines\VC\Dermatology Guidelines for Primary Care Physicians.doc 06/05/19 Problem PCP Responsibility Indication for referral Refer To EXCLUSIONS Treatment/removal of the following conditions or lesions is Referral can be certified for the following: In-panel Dermatologist NOT considered medically necessary or not a covered service: *REFFERAL OF A BENIGN

1) Spider Veins ASYMPTOMATIC LESION, 2) Cysts (unless infected) IS NOT CONSIDERED 3) Tattoos 4) / MEDICALLY NECESSARY 5) Skin Tags OR NOT A COVERED 6) Wrinkles BENEFIT. (Suggest offering to 7) Dermatolfibroma 8) Lentigines (“age/liver spots”) bill member fee for service for 9) Clinically benign nevi/mole removal of such lesions) 10) (unless painful or disabling) 11) 12) Androgenetic Alopecia (common hair loss) FOLLOW-UP CARE After consultation, routine follow-up care and Rx refills are to be done by the PCP in most circumstances. Patients will be instructed to contact dermatology to address any problems with treatment. HAIR LOSS Recommended work up and treatment: Referral can be certified for the following: In panel Dermatologist

1) TSH No improvement/regrowth noted for three or 2) For female members: DHEA-S, Testosterone and more months, while blood work is within Prolactin, 17-OH Progesterone levels normal limits. 3) Check medications patient is on as potential cause. HAIR and PROBLEMS: Recommended Treatment: Referral can be certified for the following: In-panel Dermatologist

1) Diagnose and treat common problems including but not 1) Patient not responding to standard limited to: treatment protocols.

▪ Fungal Infections *Call Dermatologist for recommendations on ▪ Ingrown Hairs treatment. ▪ ▪ Alopecia Secondary to Medication or Endocrine disorders ▪ Virilizing causes of Hirsutism LIPOMA Any symptomatic lesion less than 4cm or asymptomatic lesion Referral can be certified for the following: In panel General greater than 4cm. Surgeon Symptomatic lipoma, equal to or larger than 4cm

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MELANOMA Members with should have 3, 6, 9 & 12 month In-panel Dermatologist follow up.

OTHER DERMATOLOGICAL Any dermatological problems not clearly falling into one of the In-panel Dermatologist PROBLEMS above guidelines should be discussed with the Utilization Management Department and/or Dermatologist prior to requesting referral. PIGMENTED LESIONS Recommended Approach: Referral can be certified for the following: In-panel Dermatologist

1) Identify and perform excisional biopsy on those clinically 1) Lesion is on difficult anatomical location suspicious (i.e., nose, ears, and eyelids). 2) If pathology reveals Atypical Mole/ or Melanoma. 3) If PCP does not perform excisional . Recommended work up and treatment must include #1 & Referral can be certified for the following: In panel Dermatologist 2: Continued plaques, scaling and sharply 1) Topical corticosteroid appropriate to anatomical location demarginated lesions after at least eight for at least eight weeks weeks of conservative treatment. 2) Trial of appropriate topical cream such as Dovonex and/or Tazorac creams Recommended treatment: Referral can be certified for the following: In panel Dermatologist

1) Topical antibiotic Continuation of pustules or cysts after 8 2) Oral antibiotic weeks of both topical and oral treatment.

ROUTINE SURVEILLANCE Recommended Treatment: Referral can be certified for the following: In-panel Dermatologist

1) Identified patients with history of AK, SK or melanoma 1) Patients with history of cancerous or pre- refer to Dermatologist for yearly routine surveillance. cancerous lesions

URTICARIA Recommended Treatment: Referral can be certified for the following: In panel Dermatologist or in panel Allergist 1) Antihistamine 1) After 6 weeks of treatment, if not 2) Oral corticosteroid resolved and screening laboratory tests 3) Avoidance of potential allergens are negative. 4) H2 blockers Page 4 of 5 \\10.2.1.7\data\Quality-Internal\Policies & Procedures\UM Guidelines\VC\Dermatology Guidelines for Primary Care Physicians.doc 06/05/19 Problem PCP Responsibility Indication for referral Refer To Referral can be certified for the following: In panel Dermatologist

Depigmented macules

WARTS Recommended treatment: Referral can be certified for the In panel Dermatologist following: 1) Treat those, except on face, with topical salicylic acid solutions (i.e., Duo film), liquid nitrogen or electrocautery 1) Treatment for painful or disabling warts appropriate according to anatomical location. is unsuccessful after 12 weeks.

SOURCE: InterQual, Valley Care IPA & Valley Care Select Physicians, CMS Guidelines

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