Melanoma denials in California external review
In the California DMHC record, independent physician reviewers decided 136 published external-review cases involving melanomaand overturned the plan’s denial in 13.2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for melanoma
| Treatment | Decisions | Overturned |
|---|---|---|
| Decision Dx-melanoma | 33 | 3% |
| Decision Dx-melanoma Gene Assay | 26 | 3.8% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 128 | 9.4% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 8 | 75% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for reconstructive surgery to the back for a closed wound caused by melanoma excision. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s melanoma.At issue in this case is whether the requested reconstructive surgery to the back to repair a wound; caused by melanoma excision, is medically necessary to treat the patient’s medical condition? Does the alleged abnormality constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital defects; developmental abnormalities; trauma; infection; tumors; or disease.
Findings: The physician reviewer found that The patient has requested authorization and coverage for a positron emission tomography (PET) with computed tomography (CT) scan. . In a review of published evidence on surveillance imaging to detect metastasis in high-risk melanoma and the need for early recurrence detection, Freeman and Laks reported on a large, prospective study that demonstrated that early detection of melanoma recurrences may have a survival benefit, even accounting for lead-time bias. The authors noted that in another retrospective study of Stage III to Stage IV patients who had PET/CT scans, imaging detected 60% of recurrences and the majority of these were treated with curative intent surgery.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a DecisionDX-Melanoma test. For a thin melanoma, pathologic stage pT1a, the standard treatment involves wide excision of the lesional site with appropriate margins. In this case, a dermatopathology report from a specimen described the clinicopathologic features of the initial tumor as a thickness 0.3 mm depth, without ulceration, a mitotic index of zero, and without significant regression, which is otherwise a low risk tumor. The DecisionDX-Melanoma gene expression profiling (GEP) test resulted in a class 1a score. Under the National Comprehensive Cancer Network (NCCN) guidelines, standard treatment in this clinical setting would be re-excision with appropriate margins.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX-Melanoma genetic testing. Findings: The physician reviewer found that a thin melanoma, pathologic stage pT1a, the standard treatment involves wide excision of the lesional site with appropriate margins. In this case, a dermatopathology report described the clinicopathologic features of the initial tumor including 0.7 mm depth, without mitoses, ulceration, satellitosis, or lymphovascular invasion, which is otherwise a low-risk tumor. The DecisionDX-Melanoma gene expression profiling test (GEP) resulted in a class 1a score. Under the National Comprehensive Cancer Network (NCCN) guidelines, standard treatment in this clinical setting would be re-excision with appropriate margins followed by routine dermatologic surveillance.
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 melanoma, 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