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Skin: when insurers say no, reviewers often say yes
In 247 published external-review decisions involving skin, independent physician reviewers overturned the insurer’s denial 23.5% of the time.
Published decisions
247
2001–2026
Overturned
23.5%
58 denials reversed
Most-fought treatments for skin
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Lab Work | 54 | 5.6% |
| Genetic Genomic Test | 47 | 14.9% |
| Oncotype DX Assay | 17 | 5.9% |
| Surgery | 16 | 50% |
| PET Scan | 14 | 71.4% |
| Chemotherapy | 12 | 33.3% |
| Investigational Tx | 11 | 9.1% |
| Radiation Therapy | 6 | 33.3% |
| Clin Trial (I) | 3 | 66.7% |
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 |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 194 | 19.6% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 51 | 39.2% |
Typical time to a decision
19 days
Most land between 10 and 21 days
Handled as urgent
21.5%
Expedited when a delay would cause harm
Recent direction
Falling
29% → 19% 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
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 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.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Physician 1: This patient is a 51-year-old male diagnosed with malignant melanoma of the scalp in June 2002, treated surgically. In July 2003 he was found to have involvement of the lymph nodes in his neck, which were resected. This was followed by one year of interferon therapy. In May 2005 the patient was found to have involvement of his spleen and left hilar area; he was treated with biochemotherapy, including Temodar, platinol vinblastine, interleukin-2 (IL-2), and interferon. There was no response. He was then treated with an experimental agent, MDX-010, with again, no response. He next was treated with chemotherapy including carboplatinum, Taxol, and sorafenib, again with progression of disease.It is now proposed that the patient be treated with high dose IL-2 along with taurolidine. This treatment is the subject of a clinical trial in Dublin, Ireland.
Physician 1: The patient is a 53-year-old male diagnosed with an ocular melanoma in November 2002 and treated with surgical excision and radiation therapy. The patient was then well until he developed pain in his shoulder in the fall of 2006. He was found to have a lytic lesion in his distal clavicle, and staging CT revealed extensive metastatic disease. The patient began treatment with Nexavar and his provider recommends the addition of Abraxane to his chemotherapy regimen. The request for authorization was denied by the Health Plan on the basis that Abraxane has not been shown to be efficacious in the treatment of ocular melanoma.Abraxane is a protein-bound form of a Taxol and is approved for the treatment of metastatic breast cancer.
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 skin 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.