Mole: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with psoriasis. Previously, the patient reported a rash on her arms, back, genital area, and scalp which had been present for three months. The provider noted psoriasiform plaques were present over the patient’s scalp, lower back, right thumb, and bilateral elbows. Otezla samples were provided to the patient. Later, the provider noted psoriasiform plaques on the patient’s scalp, low back, right thumb, and bilateral elbows had improved by 30% while taking Otezla. The provider noted that the patient is not a candidate for treatment with disease-modifying antirheumatic drugs (DMARDS) or phototherapy. The patient had failed treatment with betamethasone, mometasone, and Eucrisa. The provider also noted the patient showed improvement with no adverse effects after eight weeks of treatment with Otezla.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a procedure to remove a mole from the back.At issue is whether the requested procedure to remove a mole from the back is medically necessary to treat the patient’s medical condition. In addition, does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, disease. If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Nevi (moles) are common congenital and/or acquired lesions that are seen on the skin. They can vary in size and number.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for melanoma genomic testing. The National Comprehensive Cancer Network (NCCN) guidelines state current gene expression profiling (GEP) testing does not provide clinically actionable prognostic information when compared with known clinicopathologic factors. The impact of these tests on treatment recommendations has not been established. It also remains unclear whether GEP tests can reliably predict outcomes across the risk spectrum of cutaneous melanoma, and prospective validation studies are necessary to more accurately define the clinical utility of GEP testing as part of the multidisciplinary decision-making process.

The parent of an enrollee has requested authorization and coverage for removal of a benign mole on the right cheek.Although common congenital and acquired melanocytic nevi are largely benign, they are one of the most common indications for cosmetic surgery encountered by dermatologists. Melanoma is uncommon in the pediatric age range. Only 1-2% of skin tumors excised in children turn out to be malignant when examined histologically. Some benign skin tumors of childhood tend to regress spontaneously within a few years but may cause complications at particular locations and when multiple. In this case, records indicate that the patient’s congenital nevus was noticed since kindergarten, that it has been growing over time, and that it is larger in size. Accordingly, the warning signs of malignancy are not present in this case.

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 mole was denied, the published record says the denial is worth fighting.