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Dermatitis: when insurers say no, reviewers often say yes
In 143 published external-review decisions involving dermatitis, independent physician reviewers overturned the insurer’s denial 80.4% of the time.
Published decisions
143
2001–2026
Overturned
80.4%
115 denials reversed
Most-fought treatments for dermatitis
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Skin Treatment | 79 | 82.3% |
| Biologics | 37 | 89.2% |
| Anti-inflammatories | 4 | 100% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 136 | 82.4% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 60% |
Typical time to a decision
14 days
Most land between 6 and 21 days
Handled as urgent
25.2%
Expedited when a delay would cause harm
Recent direction
Falling
94.7% → 85.7% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Physician 1: The patient is a 69 year old female that was diagnosed with breast cancer in March 1995. She was treated with lumpectomy and radiation. Subsequently, she was diagnosed with a rectal tumor in October 1995 and underwent surgery followed by chemotherapy and radiation therapy. The patient has developed radiation necrosis with soft tissue groin and perineal breakdown of a chronic nature such that blood transfusions and laser therapy have been necessary. Her provider has recommended hyperbaric oxygen (HBO) therapy for treatment of the patient’s non-healing wound.
Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with atopic dermatitis (AD). The patient reported a body and facial rash. She has been treated with doxycycline, topical steroids, including hydrocortisone and triamcinolone, and a calcineurin inhibitor Elidel. The provider noted that the patient has a long-standing history of a facial rash. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted that the patient has failed treatment with hydrocortisone, vitamin E, and Aquaphor. Physical examination findings included a well demarcated scaly plaque on the dorsal hand and scaly patches around the eyes. A biopsy was performed and revealed vesicular spongiotic dermatitis. The differential diagnosis was noted to be either allergic contact dermatitis, atopic dermatitis, or other spongiotic diseases.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that The patient has requested authorization and coverage for Adbry solution prefilled syringe 150 mg/mL. The U.S. Food and Drug Administration (FDA) has approved Adbry for the treatment of moderate-to-severe atopic dermatitis in adult patients whose disease is not adequately controlled with topical prescription therapies. A recent consensus article on atopic dermatitis experts defined moderate-to-severe atopic dermatitis as greater than 10% body surface area (BSA) involvement and/or involvement of highly visible areas or those important for function and significantly impaired quality of life. The records document that this patient has moderate-to-severe atopic dermatitis given involvement of the face and involvement of the trunk. Several recent randomized clinical trials have shown the efficacy of Adbry in treating atopic dermatitis.
Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication, Dupixent. The enrollee has eczematous dermatitis affecting 20% of his body surface area (BSA). Currently he is using betamethasone dipropionate 0.05% ointment and over-the-counter Lamisil cream on his feet. At an office visit, the enrollee’s rash had recently spread to his trunk, legs, and arms. It itched all day and worsened after narrowband ultraviolet B (nbUVB) rays. The enrollee was not a candidate for methotrexate. It was recommended the enrollee stop nbUVB, continue clobetasol 0.05% ointment and start Dupixent (dupilumab).
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for dermatitis was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.