How to appeal a Premera Blue Cross 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.

Premera Blue Cross-specific note: BCBS licensee for Washington and Alaska (~2.4M members). Express Scripts PBM. WA OIC oversight. WA has strong mental health parity enforcement and surprise-billing protections that pre-date federal NSA.

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

Cited policy: BCBS medical policy Mohs Surgery + Anthem clinical guideline Mohs Surgery and Reconstruction

Mohs per AUC; reconstruction post-Mohs (flap, graft, complex closure) coded separately per CPT (14040-14302, 15240/15260) when oncologic defect requires.

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

Where Premera Blue Cross pushes back: 1) 'Reconstruction is cosmetic'; 2) 'Could close primarily'; 3) 'Scar revision is cosmetic'.

Counter-arguments that hold up: AAD/ACMS Position Statement on Mohs Reconstruction: flap/graft/complex closure for oncologic defect is integral surgical step. Document defect size + functional preservation rationale (eyelid: prevent ectropion/entropion; nasal valve: prevent obstruction; oral commissure: prevent microstomia + speech/eating impairment). Photographs of defect support necessity. For scar revision: document specific functional deficit (contracture, ectropion, nasal valve collapse) — not cosmetic.

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

Across Premera Blue Cross'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:

• WA-specific mental health parity violations
• Step therapy via Express Scripts
• Out-of-network reductions
• Specialty drug prior auth

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 Premera Blue Cross

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 Premera Blue Cross cited in the denial.
3. File the appeal through Premera Blue Cross's portal (members: https://www.premera.com ; providers: https://www.premera.com/wa/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 WA, 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 Premera Blue Cross's prior-authorization criteria by drug: Premera Blue Cross PA criteria on ApprovalHelp.