Why is it that office visits for pigmentary disorders, such as vitiligo and hypo- and hyperpigmentation, are often covered by many health insurance plans but a diagnosis code for melasma is not?
Additionally, why are the treatments for vitiligo – including prescriptions such as corticosteroids and phototherapy – covered but treatments for melasma – including topical hydroquinone, chemical peels, and lasers – are not?
I've searched for answers to the these questions, even discussing them with my billing office, but the only answer I've been able to get is that insurance companies consider melasma to be "cosmetic." Even though both conditions may alter a person's appearance and cause cosmetic concerns, vitiligo has been delineated a medical condition because of research demonstrating that the etiology of vitiligo is autoimmune.
While melasma, like photoaging, does harbor sun exposure as a significant factor in the etiology and severity of the condition, melasma is not always due to sun exposure alone.
It has been well-documented that there is often a genetic predisposition and hormonal contribution to melasma. In clinical practice, we often see patients with hormonal shifts, because of either pregnancy or hormonal contraceptives, that develop melasma despite vigorous photoprotection.
Maybe if, in the future, a specific inherited gene is identified that shows a predisposition to melasma in certain individuals, the coverage may change.
Last year, a study was published in the Journal of Investigative Dermatology that identified upregulation of expression of certain genes associated with tyrosinase and Wnt in skin affected by melasma, as well as a down regulation of lipid metabolism associated genes, when compared with non-lesional skin (J. Invest. Dermatol. 2011;131:1692-700).
This type of research is a step in the right direction in identifying the true etiology of melasma. Until we find an answer, does anyone have any other insight as to why insurance coverage is the way it is?
- Naissan Wesley, M.D.
Do you have questions about treating patients with darker skin? If so, send them to sknews@elsevier.com.