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Skin Treatment denials: what the review data shows
Independent reviewers have decided 519 published cases where an insurer denied Skin Treatment — and they overturned the insurer 69% of the time. A denial for Skin Treatment is a starting position, not a final answer.
Published decisions
519
2001–2026
Overturned
69%
358 denials reversed
Conditions behind skin treatment denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Psoriasis | 227 | 66.5% |
| Dermatitis | 79 | 82.3% |
| Eczema | 53 | 77.4% |
| Alopecia | 46 | 87% |
| Acne | 20 | 55% |
| Rash | 7 | 57.1% |
| Autoimmune Disease | 5 | 100% |
| Arthritis | 4 | 25% |
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. | 478 | 68.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 41 | 73.2% |
Typical time to a decision
18 days
Most land between 10 and 21 days
Handled as urgent
18.9%
Expedited when a delay would cause harm
Recent direction
Rising
79.6% → 83.2% 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 Cosentyx injectables 150 mg, two times subcutaneous on week 0, 1, 2, 3, and 4. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patient’s psoriatic arthritis and psoriasis. The submitted documentation supports the medical necessity of the requested medication regimen. The American College of Rheumatology does not currently have any national guidelines for the U.S. regarding the recommendations for the treatment of psoriatic arthritis (PsA).
A 45-year-old female enrollee has requested authorization and coverage for the medication Taltz. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s plaque psoriasis. A review of the record indicates that the enrollee has been diagnosed with plaque psoriasis. The records reflect that the enrollee has a history of joint pain. The records indicate that the enrollee has tried and failed various treatments including methotrexate, clobetasol, Kenalog, and Nizoral shampoo. The enrollee has also tried Humira, and Stelara. The submitted records reflect that the enrollee has started treatment with Taltz. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
The enrollee is requesting authorization and coverage for the medication, Siliq 210 mg/1.5 ml. The enrollee has a 35-year history of psoriasis and of Hepatitis B-positive serology. He is being followed by a hepatologist and takes lamivudine, 150mg, as prophylaxis while on biologic therapy. The psoriasis is present on fifteen percent of his body surface area (BSA). He has large erythematous patches with silvery scales on his lower extremities. His fingernails show irregular pitting. He was treated with Humira for twenty months, but the provider documents a failed response to this treatment. The record indicates the enrollee has also failed treatment with topical steroids, phototherapy, Chinese medicine, acitretin and cyclosporine. Given the lack of positive response to previous medications, treatment choice has been taken into careful consideration by the provider.
Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication Otezla. The enrollee has psoriasis vulgaris. She has pink papules with collarette located on the scalp. She has used Clobetasol, 0.05% scalp solution, and Derma-Smoothe/FS Scalp oil, 0.01% but these treatments have failed. Psoriasis is affecting eight percent of her body surface area (BSA), including the scalp. The dermatologist is requesting authorization of Otezla. The dermatologist notes Otezla is Food and Drug Administration (FDA)-approved for the treatment of persons with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Additionally, the FDA does not require a trial of any specific medications prior to Otezla initiation.
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 treatment generally, not any individual case.
How to use this in your appeal
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 Skin Treatmentwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
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.