Dermatology Prior Authorization and Denial Guide
Prior authorization requirements, denial patterns, and appeal strategies for dermatology billing, grounded in Aetna Medical Policy for biologic agents for psoriasis and dupilumab/atopic dermatitis, UHC CDG Dermatology, Cigna Medical Coverage Policy for biologics for dermatologic conditions, CMS LCD for Mohs Micrographic Surgery, and AAD clinical practice guidelines.
Biologic therapy for psoriasis and atopic dermatitis: IL-17 inhibitors (secukinumab, ixekizumab, bimekizumab), IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab), and TNF inhibitors (adalimumab, etanercept) require prior authorization with documentation of moderate-to-severe psoriasis (BSA ≥10% or DLQI ≥10), failure of conventional topical therapy and at least one systemic agent (typically methotrexate, cyclosporine, or acitretin), and phototherapy trial or contraindication documentation for some payers. Dupilumab for atopic dermatitis requires documentation of moderate-to-severe AD, failure of topical corticosteroids and topical calcineurin inhibitors at adequate doses, and BSA or IGA/EASI score documentation.
Mohs Micrographic Surgery (CPT 17311–17315): covered by most payers for BCCs and SCCs meeting size and location criteria specified in the AAD/ACMS/ASDSA/ASMS Appropriate Use Criteria. Coverage for larger or higher-risk tumors in non-designated areas requires documentation of the tumor characteristics meeting the AUC criteria. Phototherapy (UVB, PUVA, excimer laser) requires prior authorization from most commercial payers and documentation of failure of topical therapies. CO-97 bundling denials are common when an E&M visit is billed on the same date as a procedure — modifier -25 documentation must clearly support a separately identifiable service.