Is intralesional triamcinolone acetonide (Kenalog) injection medically necessary for a patient with a history of keloids and previous successful response to Kenalog injections, despite no documented pain, functional limitation, or medical complications related to the hypertrophic scars?

Medical Necessity Determination for Intralesional Triamcinolone in Keloids/Hypertrophic Scars Without Documented Symptoms

Intralesional triamcinolone acetonide for keloids and hypertrophic scars is NOT medically necessary in the absence of documented pain, functional limitation, or medical complications, as treatment without these qualifying symptoms constitutes cosmetic intervention which is excluded from coverage.

Critical Coverage Criteria

The fundamental issue here is distinguishing medical necessity from cosmetic intervention. The evidence provided focuses entirely on infantile hemangiomas (IHs), not keloids or hypertrophic scars, making these guidelines irrelevant to this authorization question 1.

Medical Necessity Requirements for Keloid/Hypertrophic Scar Treatment

Documentation must include at least one of the following:

• Pain: Documented patient-reported pain directly attributable to the scar tissue 2, 3
• Functional limitation: Restricted range of motion, interference with activities of daily living, or impairment of normal anatomic function 2, 3
• Medical complications: Active inflammation, recurrent infection, or tissue breakdown 2, 3

Why Previous Response to Treatment Does Not Establish Current Medical Necessity

A history of successful Kenalog treatment for keloids does not independently justify continued treatment without current symptoms. 2, 3 The fact that a patient previously responded well to intralesional corticosteroids only demonstrates treatment efficacy when medical necessity existed at that time—it does not create ongoing medical necessity in the absence of current qualifying symptoms.

Evidence Analysis for Keloids and Hypertrophic Scars

Efficacy Data

Intralesional triamcinolone acetonide demonstrates variable efficacy for keloids and hypertrophic scars:

• Response rates: 50-100% regression reported, but with recurrence rates of 33% at 1 year and 50% at 5 years 4
• Short-term benefits: Significant improvement in vascularity and pliability compared to verapamil 2
• Medium to long-term: 5-FU alone or combined with TAC shows superior results for scar height, pliability, and pigmentation 2, 5, 3

Safety Concerns

Significant adverse effects occur with TAC injections at standard concentrations (20-40 mg/mL): 2, 6, 3

• Skin atrophy (dose-dependent and more likely at higher concentrations)
• Telangiectasia
• Hypopigmentation
• Precipitation of TAC crystals at injection sites

The combination of TAC with 5-FU demonstrates lower overall complication rates compared to TAC alone 5, 3, suggesting that if medical necessity were established, combination therapy would be preferable.

Clinical Decision Algorithm

Step 1: Review documentation for qualifying symptoms

• Is there documented pain attributable to the scar? 2, 3
• Is there documented functional limitation? 2, 3
• Are there documented medical complications? 2, 3

Step 2: If NO qualifying symptoms are documented

• Non-certify: Treatment is cosmetic and excluded from coverage
• Request additional documentation if symptoms exist but were not documented

Step 3: If qualifying symptoms ARE documented

• Certify: Medical necessity is established
• Consider recommending TAC + 5-FU combination over TAC alone for superior efficacy and safety profile 5, 3

Common Pitfalls to Avoid

Do not conflate treatment efficacy with medical necessity. The literature demonstrates that intralesional TAC can effectively reduce keloid size and improve appearance 2, 4, but this does not mean all keloid treatment is medically necessary. Without symptoms causing morbidity or functional impairment, scar reduction is cosmetic.

Do not assume prior authorization establishes ongoing medical necessity. Previous successful treatment indicates the patient is a responder to therapy, but each treatment episode requires independent documentation of current medical necessity 2, 3.

Do not rely on diagnosis alone. A diagnosis of keloids with history of successful Kenalog response describes the patient's condition and treatment history, but does not document current symptoms requiring intervention 2, 3, 4.

Recommendation

Non-certify this request unless the provider can supply documentation of current pain, functional limitation, or medical complications related to the hypertrophic scars. The reviewed literature supports efficacy of intralesional triamcinolone for symptomatic keloids and hypertrophic scars 2, 3, 4, but efficacy alone does not establish medical necessity when treatment is purely for cosmetic improvement.