Stakeholder Review: MDC 09 Dermatology & Plastic Surgery Policies (Feedback by Mar 5, 2026)

Premera Blue Cross has posted a stakeholder review notice (feedback due March 5, 2026) listing multiple MDC 09 Dermatology & Plastic Surgery policies under consideration, including scar/wound management, breast reconstruction, and body-contouring procedures. Policies called out for review include fractional CO2 laser for hypertrophic scars/keloids, recombinant/autologous platelet-derived growth factors for wound healing, adipose-derived stem cells in autologous fat grafting to the breast, panniculectomy and excision of redundant skin, and reconstructive breast surgery/implant management. The document is an intake notification only and does not contain revised coverage language, criteria, or coding changes; it identifies topics open for feedback. This review is part of a broader multi-specialty policy cycle that includes other non-dermatology items also open for comment.

Cigna update: Clarified criteria for breast implant removal and capsulectomy (4/15/2026)

Effective April 15, 2026, Cigna clarified coverage for removal and capsule surgery of saline and silicone breast implants, specifying when explantation is medically necessary versus cosmetic. Explantation and capsular procedures are covered when related to breast reconstruction, confirmed silicone rupture/extrusion on imaging, interference with cancer diagnosis/treatment, infection unresponsive to medical therapy, implant exposure, Baker Grade IV contracture, tissue necrosis, BIA-ALCL/BIA-SCC, or use of Allergan BIOCELL textured devices. Removal of intact silicone implants solely for suspected autoimmune disease, breast implant illness, or cancer prevention, as well as replacement or mastopexy for cosmetic reasons, are considered not medically necessary. The policy reiterates that saline ruptures alone are typically cosmetic unless other indications exist and that MRI may be required to confirm silicone rupture when other imaging is inconclusive.

Cigna: Rhofade (oxymetazoline) Not Covered for Persistent Rosacea Erythema

Effective 2026-03-15, Cigna classifies oxymetazoline (Rhofade) as not medically necessary when used to treat persistent (nontransient) facial erythema associated with rosacea and lists it under Conditions Not Covered. The policy explains this is consistent with a broader cosmetic-exclusion: treatments intended to correct the cosmetic sequelae of rosacea (e.g., erythema, telangiectasia) are considered cosmetic and not covered. The update acknowledges the FDA indication and AARS guidance noting topical alpha‑agonists can reduce erythema quickly, but clarifies that such pharmacologic treatment for persistent erythema remains excluded from coverage. Providers should not expect coverage for Rhofade when prescribed solely for persistent rosacea-related erythema.

Rinvoq Criteria Consolidated — Indication‑Specific Starts, Renewals & Prescriber Rules

Cigna updated Rinvoq (JAK inhibitor) coverage criteria effective 2026-03-15, consolidating indication-specific initiation, renewal, formulation limits, and prescriber requirements across dermatology, rheumatology, and gastroenterology indications. Initial approval durations now vary by indication (e.g., 3 months for atopic dermatitis ≥12 years; 6 months for psoriatic arthritis, rheumatoid arthritis, Crohn’s and other rheumatologic indications) with explicit prior‑therapy requirements (including TNFi trial for rheumatologic/Crohn’s indications and specified biologics or systemic agents for dermatology). Renewal approvals allow up to 1 year when patients meet condition‑specific minimum treatment durations and demonstrate objective clinical benefit using listed instruments or symptom improvements (e.g., BSA/pruritus for atopic dermatitis; ASDAS/BASDAI for axial disease; DAPSA/MDA for psoriatic arthritis). Specialist prescriber or consultation requirements are reinforced by indication (dermatology/allergy/immunology for AD, gastroenterology for Crohn’s, rheumatology for arthritis/axial disease).

4/15/2026: Category III Code Consolidation — Dermatology & Plastic Surgery (Skin/Breast)

Cigna updated Medical Coverage Policy 0558 effective 4/15/2026 to consolidate Category III and related CPT code guidance under the Dermatology & Plastic Surgery (Skin/Breast) resource listing. The revision enumerates multiple Category III codes (e.g., 0960T, 0967T–0980T, 0351T, 0489T and others) that are designated experimental/investigational in this policy excerpt while calling out coding descriptions, reporting constraints, and cross‑coding guidance (for example, percutaneous laser ablation, cryoablation, and intraoperative OCT of excised breast tissue). The update cross‑references related Cigna coverage resources where certain Category III codes are considered medically necessary for specific indications (for example Scar Revision and select cardiac or cellular therapy policies), so providers should consult those indication‑specific policies for coverage determination. Review the policy text for precise code‑level reporting notes and do‑not‑report combinations prior to claim submission.

Simponi Aria (golimumab IV) PsA Coverage Criteria — 12‑Month Limits

UnitedHealthcare’s March 2026 update defines structured coverage criteria for IV golimumab (Simponi Aria) in adults with active psoriatic arthritis, separating clear pathways for initial and continuation therapy and requiring FDA‑labeled dosing. Initial approval requires either a failed 3‑month methotrexate trial (unless contraindicated), prior use of an FDA‑approved targeted immunomodulator for PsA, or current Simponi Aria use; at least one pathway requires rheumatologist or dermatologist involvement. Continuation requires prior receipt of the IV formulation, documented clinical response, and no concurrent systemic targeted immunomodulators for the same indication. All initial and reauthorization approvals are limited to a maximum of 12 months. The policy references a randomized placebo‑controlled trial demonstrating golimumab’s ACR20 benefit, improved enthesitis/dactylitis scores, and inhibition of structural progression.

Cigna adds adalimumab biosimilars and updates indication criteria (MDC 09)

Cigna updated its MDC 09 (Dermatology & Plastic Surgery) adalimumab coverage to add biosimilars/unbranded products adalimumab-aaty (Yuflyma) and adalimumab-bwwd, stating they follow the same criteria as other subcutaneous adalimumab products and adding Q5140–Q5145 codes (effective 1/1/2025). The policy refines indication-specific initial and continuation rules: hidradenitis suppurativa initial approvals for 3 months (age ≥12, prior therapy trial, dermatologist involvement) with 1‑year continuation after ≥3 months of benefit; plaque psoriasis initial approvals for 3 months (age ≥18, trial of a traditional systemic agent or specified exceptions). Additional 2025 edits clarified ulcerative colitis initial-therapy language and added exceptions allowing prior trial or intolerance to another biologic, Otezla/Otezla XR, or Sotyktu to meet psoriasis step requirements. Continuation approvals across indications require objective improvement from baseline, and guideline references and an appendix place adalimumab among biologic and oral alternatives.

Premera: New MDC‑09 Non‑Covered Codes for Skin/Breast Procedures (Mar 2026)

Premera Blue Cross updated the MDC 09 (Dermatology & Plastic Surgery — Skin/Breast) non‑covered/experimental coding list effective 2026‑03‑01, adding several new Category III and other codes for emerging dermatologic and breast procedures. Newly listed codes include adipose‑derived regenerative cell therapy for scleroderma of the hands (0489T, 0490T), molecular fluorescent nevus imaging (0700T, 0701T, e.g., Orlucent), and percutaneous breast tumor ablation (0970T, 0971T). The policy groups these with other novel imaging, quantitative MR, device and procedural codes (e.g., 0698T series) to clarify they are considered experimental/investigational and non‑covered under MDC 09. Providers should review these additions when submitting or authorizing services related to these technologies.

Cigna: Infliximab Dermatology Criteria Consolidated — Mar 15, 2026

Cigna updated and consolidated infliximab dermatology coverage (effective 2026-03-15) within Drug Coverage Policy IP0660, specifying FDA‑based dosing, approval durations, and indication-specific criteria for plaque psoriasis, hidradenitis suppurativa, and pyoderma gangrenosum (also covering related uses such as immunotherapy toxicities and sarcoidosis). Initial approvals are time‑limited (typically 3 months for psoriasis and HS; 4 months for pyoderma gangrenosum) with requirements for prior therapies or contraindications and dermatologist involvement. Continuation approvals for patients already on an infliximab product allow 1‑year coverage when the patient has been on therapy for the specified minimum (≥3 months for psoriasis/HS; ≥4 months for pyoderma gangrenosum) and shows objective and symptom‑based clinical improvement. Dosing is standardized: initial regimens up to 5 mg/kg with maintenance no more often than every 8 weeks, and established patients may receive up to 10 mg/kg no more often than every 4 weeks.

Noncoverage: Home Ultraviolet Phototherapy (PUVA/UV) — Blue CHiP

Blue CHiP (Medicare and commercial) restates that home ultraviolet phototherapy (including PUVA and other home UV modalities) for dermatologic conditions is not covered, characterizing home use as a convenience rather than medically necessary. The policy notes FDA 510(k) clearance for a handheld UVB device but finds overall evidence insufficient to demonstrate home therapy is as safe or effective as office-based phototherapy. Key clinical concerns include lack of periodic dermatologist skin examinations, potential to miss early skin cancer, and limited comparative studies validating home PUVA or other home UV treatments. A single open-label trial showing comparable efficacy for home oral PUVA in hand eczema is acknowledged but deemed insufficient to change the noncoverage determination.