Is excision of bilateral ear keloids with full-thickness skin grafts, immediate post-op radiation, removal and replacement of the left ear implant, and right tragus revision medically necessary for a patient with a history of bilateral ear reconstruction, recurrent ear infections, and severe bilateral keloid scarring?

Medical Necessity Determination for Bilateral Ear Keloid Excision with Adjuvant Therapies

Direct Recommendation

The proposed surgical intervention—bilateral ear keloid excision with full-thickness skin grafts, immediate postoperative radiation, removal and replacement of the left ear implant, and right tragus revision—is medically necessary for this 5-year-old male with severe bilateral keloid scarring causing recurrent infections and antibiotic resistance.

Rationale and Clinical Justification

Primary Medical Indication: Infection Control

The recurrent infections with documented antibiotic resistance represent a compelling medical indication for surgical intervention. 1

• The patient has progressed from Cephalexin-responsive infections to requiring Bactrim due to bacterial resistance, indicating escalating severity 1
• Bacteria trapped within keloid folds create a persistent infectious nidus that cannot be adequately managed with conservative measures alone 1
• The presence of swelling and erythema at presentation demonstrates active infection requiring definitive treatment 1

Implant-Related Complications

Removal of the infected left ear implant meets MCG criteria for "removal of implanted device needed (eg, infection, complication, pain)" 1

• The Osia 2 sound processor implant is compromised by surrounding keloid tissue and recurrent infections 1
• Replacement after keloid excision is necessary to restore hearing function in a child with maximum conductive hearing loss from bilateral aural atresia 1
• The implant serves a critical functional role for auditory access, speech development, and learning in this 5-year-old child 1, 2

Keloid Management Evidence Base

Multimodal therapy combining surgical excision with adjuvant treatments achieves superior outcomes compared to single-modality approaches for ear keloids. 3, 4, 5, 6

• The "fillet technique" (meticulous peeling of keloid skin) combined with postoperative radiation and steroid injections achieved 0% recurrence rates in one prospective study 3
• Surgical excision with postoperative radiation reduces recurrence rates from 50-80% (surgery alone) to below 10% with optimized protocols 4, 5
• For ear keloids specifically, multimodal therapy reduced recurrence from 40% (single therapy) to 14.3% (dual therapy) to 0% (triple therapy) 3
• Postoperative radiation protocols for ear keloids typically employ 8 Gy/1 fraction for earlobes or 15 Gy/2-3 fractions for other ear sites 5

Conservative Treatment Failure

The patient has exhausted appropriate conservative measures, making surgical intervention the next appropriate step. 1, 3

• Steroid injections provided only "minimal improvement" 3, 7
• Multiple courses of antibiotics demonstrate inadequate infection control 1
• The 20-month interval since initial reconstruction (March 2024 to present) represents sufficient observation time 1

Urgency Factors

The development of antibiotic resistance and ongoing active infection create urgency for definitive surgical management. 1

• Failure of first-line antibiotic (Keflex) necessitating switch to Bactrim indicates progressive bacterial resistance 1
• Continued conservative management risks further resistance development and potential systemic complications 1
• In pediatric patients, recurrent infections can impact quality of life, school attendance, and developmental progress 1

CPT Code Justification

CPT 20680 (Removal of Implant; Deep)

Medically necessary for removal of infected left ear Osia 2 sound processor that cannot function properly within infected keloid tissue 1

CPT 69716 (Implantation of Osseointegrated Implant, Skull)

Medically necessary to restore hearing function after keloid excision in a child with bilateral aural atresia and maximum conductive hearing loss 1

CPT 11421 (Excision of Benign Lesion)

Medically necessary for bilateral keloid excision as definitive treatment of recurrent infection source 3, 4, 5, 6

CPT 21086 (Auricular Prosthesis)

Medically necessary for reconstruction following keloid excision and tragus revision to restore ear anatomy 3, 5, 6

CPT 69399 (Unlisted Procedure, External Ear)

Medically necessary for specialized procedures including full-thickness skin grafting and immediate postoperative radiation specific to this complex case 3, 4, 5, 6

Critical Caveats and Pitfalls

Radiation Timing and Dosing

• Postoperative radiation must begin within 24-72 hours of surgery for optimal efficacy 4, 5, 6
• Ear keloids require lower radiation doses (8-15 Gy) compared to chest keloids (18 Gy) to minimize side effects while maintaining efficacy 5
• The proposed 2-3 day radiation course aligns with evidence-based protocols 4, 5, 6

Pediatric Considerations

• While most keloid studies involve adults, the medical necessity in this pediatric case is driven by infection control and hearing preservation rather than cosmesis alone 1
• The child's age (5 years) places him in a critical period for speech and language development, making hearing restoration particularly important 1, 2
• Radiation exposure in children requires careful consideration, but the low doses used for keloid treatment (8-18 Gy total) are well below thresholds for significant long-term effects 5, 6

Adjuvant Steroid Therapy

• Intralesional triamcinolone injections should be administered immediately if any signs of recurrence appear during follow-up 3, 4
• Early intervention with steroids at first sign of recurrence significantly improves long-term outcomes 4

Conclusion on Medical Necessity

All proposed CPT codes are medically necessary based on:

1. Documented recurrent infections with antibiotic resistance requiring definitive source control 1
2. Failed conservative management with steroid injections 3, 7
3. Compromised hearing implant function requiring removal and replacement 1
4. Evidence-based multimodal approach (surgery + radiation + skin grafting) demonstrating superior outcomes for ear keloids 3, 4, 5, 6
5. Urgency created by progressive bacterial resistance and active infection 1