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

The framework that applies to your appeal

Medicare Advantage plans follow a separate appeal track from commercial plans. Reconsideration must be requested within 60 days; if the plan misses its deadline, the case auto-forwards to the IRE (Maximus).

Humana-specific note: Heavily Medicare Advantage focused. MA-specific appeal track (42 CFR Part 422 Subpart M) applies — 60 days to request reconsideration, NOT the 180 days for commercial plans. Auto-forward to IRE (Maximus) if Humana misses deadline.

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

Cited policy: Humana Medicare Advantage — defers to NCCN Skin Cancer + AAD; case-by-case medical necessity for PDT

PDT (MAL/ALA-PDT) for biopsy-proven sBCC, SCCIS, or AK field cancerization per AAD AK Guideline (Eisen 2021); failure or intolerance of topical therapy supports PDT.

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

Where Humana pushes back: 1) 'Surgery should be used'; 2) Topical therapy not tried first; 3) PDT for BCC 'investigational'.

Counter-arguments that hold up: AAD AK Guideline (Eisen J Am Acad Dermatol 2021) supports MAL/ALA-PDT for AK and field cancerization; AAD Position Statement on PDT supports superficial BCC and SCCIS. Document biopsy confirmation + photographic documentation of field. For sBCC: cite Roozeboom J Am Acad Dermatol 2012 long-term efficacy. Topical 5-FU/imiquimod failure or intolerance documented when applicable.

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

Across Humana'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:

• MA plan step therapy on Part B drugs
• Skilled nursing facility days
• Prior auth on specialty drugs
• OON emergency 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 Humana

1. Read the denial letter — note the exact denial reason code and the appeal deadline (60 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 Humana cited in the denial.
3. File the appeal through Humana's portal (members: https://www.humana.com ; providers: https://www.humana.com/provider). 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 KY, 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 Humana's prior-authorization criteria by drug: Humana PA criteria on ApprovalHelp.