How to appeal an Aetna mohs surgery & dermatologic surgery — bcc, scc, melanoma in situ, slnb, pdt denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Aetna-specific note: Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.

What Aetna's policy requires for mohs surgery & dermatologic surgery — bcc, scc, melanoma in situ, slnb, pdt

Cited policy: Aetna Clinical Policy Bulletin Mohs Micrographic Surgery

Mohs AUC mapping required; Area H broadly covered; Area M/L requires additional risk factors (recurrent, aggressive subtype, ill-defined, large, immunosuppressed); biopsy with histologic subtype.

How Aetna denies mohs surgery & dermatologic surgery — bcc, scc, melanoma in situ, slnb, pdt — and how to counter it

Where Aetna pushes back: 1) Trunk/extremity Mohs questioned ('use WLE'); 2) Tumor size 'too small for Mohs'; 3) Histologic subtype not aggressive enough.

Counter-arguments that hold up: Submit AUC table mapping with explicit score. Document recurrent / immunosuppression / aggressive subtype / ill-defined borders for Area M/L. Mosterd 2008: high-risk BCC Mohs vs WLE 10-yr recurrence 4.4% vs 12.2%. Tissue conservation rationale for sub-cm tumors in cosmetically/functionally sensitive locations. Quote subtype verbatim from biopsy report.

What Aetna typically denies for mohs surgery & dermatologic surgery — bcc, scc, melanoma in situ, slnb, pdt

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For mohs surgery & dermatologic surgery — bcc, scc, melanoma in situ, slnb, pdt, expect:

• UM-2575 medical necessity denials
• Prior auth absent
• Step therapy on specialty drugs
• Out-of-network ER reduction

Treatments most often denied in this category

These are the mohs surgery & dermatologic surgery — bcc, scc, melanoma in situ, slnb, pdt treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Mohs (Area H)
• Mohs (Area M/L per AUC)
• Mohs for melanoma in situ
• Wide local excision (BCC/SCC)
• Wide excision (melanoma)
• SLNB (melanoma)

How to submit the appeal to Aetna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Aetna cited in the denial.
3. File the appeal through Aetna's portal (members: https://www.aetna.com ; providers: https://www.aetnaprovider.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Aetna's prior-authorization criteria by drug: Aetna PA criteria on ApprovalHelp.