Mohs Micrographic Surgery denials: what the review data shows

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mohs micrographic surgery (MMS). According to the guidelines for the care and management of primary cutaneous melanoma, surgical excision with appropriate margins is the recommended treatment for MIS. These guidelines recommend a surgical margin of 0.5 to 1 cm. Per the National Comprehensive Cancer Network (NCCN) guidelines, there is a lack of randomized trials to inform peripheral surgical margins or the depth of WLE for MIS. The NCCN guidelines provide that MMS can be considered for minimally invasive melanomas in anatomically constrained areas, such as the face. In this case, the patient has MIS located on the nose. The pathological features of the patient’s MIS are unusual.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs surgery for treatment of the enrollee who was diagnosed with a nodular basal cell carcinoma. Findings: The physician reviewer found that there is support in the medical literature for the requested procedure in this clinical setting. The patient requested Mohs surgery for the treatment of a basal cell carcinoma which is located on the left side of her nose. The guidelines indicate that Mohs surgery is recommended for treatment of basal cell carcinoma involving the head and neck, irrespective of the size of the lesion. The size of the biopsy specimen is not necessarily related to the size of the lesion. The pathology specimen was 2 mm (after shrinkage which occurs in the skin once removed from the body).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mohs surgery. Treatment of basal cell carcinomas should follow appropriate dermatology society guidelines for appropriateness of treatment as well as consider patient characteristics while maximizing efficacy and minimizing recurrence risk. This patient has a biopsy proven basal cell carcinoma of nodular subtype on her left upper arm, with biopsy size of 9 mm. The appropriateness of Mohs micrographic surgery is best detailed by the Appropriate Use Criteria (AUC) for Mohs micrographic surgery. By this criteria, a 9 mm primary non-recurrent superficial or nodular basal cell carcinoma on the arms (left area) in a healthy patient (not immunocompromised) would have an AUC score of 3, which would be an inappropriate indication for Mohs micrographic surgery.

Nature of Statutory Criteria/Case Summary: The patient presented to her primary care provider. The records noted a growing skin lesion on the upper left back. This lesion had been present for approximately one year, has gradually increased in size, and has been bleeding intermittently. The provider noted that the patient is fair skinned with multiple freckles. There was no personal history of skin cancer noted. The records noted basal cell carcinoma. The treatment plan included the performance of Mohs micrographic surgery to the left scapular back. The patient has requested authorization and coverage for Mohs micrographic surgery. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested services.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Mohs Micrographic Surgerywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.