How to appeal a Cigna 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.

Cigna-specific note: Sold its Medicaid Advantage book to HCSC in 2023. Express Scripts (PBM) is Cigna-owned. Frequent class-action litigation around mental health parity.

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

Cited policy: Cigna coverage policy Mohs Micrographic Surgery + 0259 Sentinel Lymph Node Biopsy for Melanoma

Mohs per AUC + AAD; SLNB per NCCN Melanoma + ASCO/SSO Wong 2018: clinically node-negative cutaneous melanoma with Breslow >=0.8mm OR <0.8mm with ulceration/high mitotic rate.

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

Where Cigna pushes back: 1) Breslow <0.8mm — 'too thin for SLNB'; 2) MSLT-I 'no overall survival benefit'; 3) SLNB 'staging only, not therapeutic'.

Counter-arguments that hold up: NCCN + ASCO/SSO support SLNB at Breslow 0.8-1.0mm (discuss) and >=1.0mm (recommend). For Breslow <0.8mm with ulceration/high mitotic rate, ASCO/SSO supports discussion + decision-making. MSLT-I established SLN status as strongest prognostic factor (10-yr DSS hazard ratio 1.81 for + vs - SLN). Drives adjuvant therapy eligibility (Stage IIB/IIC/III nivolumab/pembrolizumab). MSLT-II showed observation acceptable post-positive SLN, reinforcing SLNB role for staging.

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

Across Cigna'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:

• Mental health parity violations
• Step therapy
• Specialty drug prior auth
• OON balance billing disputes

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 Cigna

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 Cigna cited in the denial.
3. File the appeal through Cigna's portal (members: https://my.cigna.com ; providers: https://cignaforhcp.cigna.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 Cigna's prior-authorization criteria by drug: Cigna PA criteria on ApprovalHelp.