Basal Cell Carcinoma denials in California external review
In the California DMHC record, independent physician reviewers decided 27 published external-review cases involving basal cell carcinomaand overturned the plan’s denial in 33.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for basal cell carcinoma
| Category | Decisions | Overturned |
|---|---|---|
| Mohs Micrographic Surgery | 6 | 50% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 20 | 40% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 7 | 14.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for any or all of the additional components of the requested image-guided superficial radiation therapy services [therapeutic radiology treatment planning; therapeutic radiology simulation-aided field setting, simple; therapeutic radiology simulation-aided field setting, intermediate; treatment devices, design and construction, complex; medical radiation physics, dosimetry, treatment devices, and special services; radiation treatment management; and ultrasonic guidance for placement of radiation therapy fields] in addition to the authorized services [radiation treatment delivery, superficial and/or orthovoltage, per day; therapeutic radiology simulation aided field setting, and basic radiation dosimetry calculation].
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for scar revision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s scar after removal of basal cell carcinoma.The submitted documentation supports the medical necessity of scar revision. Skin cancer is the most common of all cancers. Mohs surgery is an effective technique for removing common types of skin cancer. A successful reconstruction mimics the premorbid state and maintains function. The goal is to achieve optimal cosmetic and functional results while minimizing stages and resection of healthy tissue, with good contour the aesthetic endpoint.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high dose rate (HDR) brachytherapy with Leipzig applicator for treatment of the enrollee’s basal cell carcinoma. Findings: The 3 physician reviewer found that Basal cell carcinoma is a non-melanoma skin cancer which develops in response to long-term sun exposure. The standard of care for basal cell carcinoma on the nasal tip is considered to be Mohs micrographic surgery for margin control. The use of brachytherapy is not considered to be standard of care for the treatment of basal cell carcinoma on the nasal tip.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high-dose rate (HDR) electronic brachytherapy. The treatment of basal cell carcinomas (BCC) should follow appropriate American Society for Dermatologic Surgery guidelines as well as consider patient characteristics while maximizing efficacy and minimizing recurrence risk. The records indicate that this patient has biopsy proven BCC of nodular subtype on his right cheek. The patient is being considered for treatment with HDR electronic brachytherapy. For BCC on the face, Mohs surgical treatment has been demonstrated to yield superior health outcomes and lowest rate of recurrence as compared to other interventions. Per the National Comprehensive Cancer Network (NCCN) guidelines, radiation therapy is appropriate for the treatment of BCC for patients who are not surgical candidates.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving basal cell carcinoma, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY