Payer guide · Aetna and Cigna
Aetna and Cigna Dermatology Billing: Policy Bulletins and Coverage
Both payers publish detailed clinical policy positions, and both apply them literally. For dermatology the sharpest edges are cosmetic exclusions written more broadly than Medicare's, step-therapy requirements before a biologic is approved, and coverage criteria for procedures like laser treatment and excision of benign lesions that a note has to meet word for word.
Read the policy before the prior authorization
Each payer's clinical policy states the covered indications, the required prior therapies and the documentation elements. Submitting an authorization without meeting each stated element produces a denial that is then argued for months over facts that were available on day one.
For biologics, the required elements are usually body surface area or severity scoring, the specific prior therapies tried with dates and outcomes, and a statement of failure or intolerance. Missing dates are the single most common reason for a denied biologic request.
Cosmetic exclusions are broader than Medicare's
- Services described as improving appearance without a functional indication are excluded outright, regardless of diagnosis code.
- Where a service has both a medical and a cosmetic use, the note must state the functional impairment being treated.
- Collect the self-pay portion before the service where the exclusion is known, with a signed financial agreement, rather than chasing it after the denial.
Appeals and peer review
Both payers offer a clinical peer-to-peer step on medical necessity denials. Using it early, while the case is still with the medical director rather than in a formal appeal queue, resolves a meaningful share of biologic and procedure denials without paperwork.
Where a denial is contractual rather than clinical, the peer path is the wrong route and delays the appeal window. Sort denials into clinical and administrative before choosing the path.
Frequently asked questions
Why was our biologic authorization denied when the patient clearly qualifies?
Most often because prior therapy dates or outcomes were absent from the submission. The clinical picture is rarely the dispute; the documentation of step therapy is.
Is a peer-to-peer worth the provider's time?
On medical necessity denials for biologics and higher-cost procedures, usually yes — it is faster than a written appeal and the reviewer can approve on the call.