The two steps after a refusal
Internal appeal to the plan
You ask the same insurer to look again, using the file your dermatology office puts together.
External review by an independent third party
If your case qualifies, someone outside the insurance company gets the final say. Follow the steps printed on your own denial notice.
My plan turned down ___ because my psoriasis covers too little of my body
The 10% body-surface figure is one of three routes in, not a gate all three have to pass. The International Psoriasis Council scrapped the mild, moderate and severe scale and set three criteria, any one of which makes you a candidate for systemic treatment. Where your patches are is one of them, on its own, whatever percentage they add up to. Evidence Evidence
- Psoriasis on 10% or more of your body surface, or
- psoriasis on a high-impact site: the face, palms, soles, genitals, scalp or nails, or
- topical treatment that has not controlled it.
Why this matters
- Sources cited, not yet graded
I read the National Psoriasis Foundation position statement dated 30 December 2025, which adopted the same shape. It says moderate-to-severe psoriasis "is not determined solely by body surface area (BSA) involvement of 10%". Psoriasis on the face, scalp, hands, feet, nails or genitals counts as moderate-to-severe too. Its closing line is the one I would quote into an appeal: people with psoriasis should never be denied advanced care because of outdated measures. IPC was blunt about the audience for this work. It listed payers among the groups it set out to move, and named refusal to pay as a result of the older scale.
Considerations
- Depends on you
Neither body writes plan policy. A plan can set its own rule, and plenty still run on a flat percentage. What binds your plan sits in your plan's own published policy, not in either statement. I compared two places in IPC's own June 2025 teaching deck and they state its threshold differently. One says 10% or more, the other says above 10%. Quote the criterion you meet rather than arguing the boundary.
Questions for your plan or your dermatology office
Which published severity criterion did you apply to this decision, and does it recognize high-impact sites?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Where is that criterion written down so I can read the version you used?
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The letter says I have to fail a topical first. How much counts as failing?
The field has put a number on it. IPC defines failed topical therapy as not reaching clear or almost-clear skin. It sets that mark at 1% or less body surface, with a physician global assessment of 0 or 1, over two four-week courses in a row. If your plan asks for failure without saying what failure is, there is a published definition to point at. Evidence
Why this matters
- Sources cited, not yet graded
IPC puts the same thing plainly. If you are under the 10% mark and topical medicine alone is not controlling your patches, you are a candidate for systemic treatment. That makes the question a matter of what your chart records, not a disagreement about medicine.
Considerations
- Depends on you
This is the council's definition, not a regulation and not your plan's. A plan may want a longer trial, particular drugs, or a specific documented order, and its own written criterion is what decides your case. The consensus stops at candidacy: it does not name which systemic treatment comes next, and it sets no dose or schedule.
Questions for your plan or your dermatology office
What does this plan count as a failed topical course: which drugs, for how long, and measured how?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Does the record you reviewed list every topical I have already tried, with its dates?
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The appeal gets written out of my chart. What needs to be in there?
Both criteria above are answered by the record or not at all. A chart that names the affected sites and lists each topical with its dates answers both. A chart that says "psoriasis, ongoing" answers neither, and a reviewer reading it has nothing to overturn the decision with. Evidence
- The sites, named: scalp, nails, palms, soles, face, genitals, whichever apply.
- Each topical you have used, with when you started, when you stopped, and what happened.
- Dated photos of the same patch, same light, same distance, so the record shows a course rather than one bad day.
Why this matters
- Sources cited, not yet graded
Your dermatology office writes the clinical substance of an appeal, and it can only cite what is already in the notes. Asking for the sites and the topical history to be stated plainly is a records request. It is the cheapest thing you can do before the paperwork goes back. People I have heard from describe skin folds and the groin as the area they never showed a clinician at all.
Considerations
- Depends on you
A complete record does not oblige a plan to approve anything, and none of this changes the criterion the plan applies. The deadline that governs your filing is printed on the denial notice itself, not here.
Questions for your plan or your dermatology office
Can my notes name the affected sites and list every topical with its dates before this goes back?
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Who is saying this, and what do they stand to gain?
Both groups take money from the companies whose drugs this definition unlocks. IPC lists AbbVie, Johnson & Johnson, Eli Lilly, Novartis and Takeda among its top-tier corporate members, with LEO Pharma, UCB, Amgen and others below them. NPF publishes a similar roster. A broader definition of who qualifies for a systemic drug is a broader market for every one of them. Evidence Evidence
Why this matters
- Sources cited, not yet graded
That does not make the criteria wrong, and it does not weaken them in an appeal. They are published, dated and citable, which is what a reviewer can act on. Showing a reviewer the field's own current definition of severity is showing them something real.
Considerations
- Depends on you
It does mean these are the positions of interested parties, not a neutral referee. I checked IPC's corporate-members page, and it says nothing about how that money relates to its editorial independence. Your plan's own written criterion is still the document that decides your case, so read that one yourself.
Questions for your plan or your dermatology office
Where can I read this plan's severity criterion in writing, rather than a summary of it?
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What happens after the first refusal
A refusal is not the last word on a US plan decision. HealthCare.gov describes an inside appeal to the plan itself, then an outside review by an independent third party when a case is eligible. Follow the steps printed on the notice in your hand, not a general description of the process. Evidence
- Internal appeal: the same insurer looks again, using the file your dermatology office puts together.
- External review: if your case qualifies, someone outside the insurance company gets the final say.
Why this matters
- Sources cited, not yet graded
The record from the "chart" question above is what an appeal file is built from. The affected sites, named. Every topical tried, with dates. Dated photos showing a course rather than one bad day.
Considerations
- Depends on you
This page sets no one deadline for all readers, and does not promise that a case gets an outside review. Filing windows and fast-track routes shift by plan and by state. The notice in your hand states your own steps and dates.
Questions for your plan or your dermatology office
What is the filing deadline printed on this notice, and is an expedited route open?
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Evidence behind this page
Sources
Each evidence badge opens the source and its limits. The full list stays available here.
- HealthCare.gov, U.S. Centers for Medicare & Medicaid ServicesRegulatory · Regulatory / guideline, tier 1Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports a general US individual and group health-plan distinction between internal appeal and eligible external review, and the need to use the denial notice for instructions.
What it does not support
Rights, deadlines, urgent pathways and external-review availability vary by plan and jurisdiction, so this source does not supply a universal deadline or guarantee review.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- International Psoriasis CouncilGuideline · Clinical research, tier 2Relevant relationship disclosed
- Published
- SteadySkin last checked
What this source can and cannot tell you
Why the independence label says this: The International Psoriasis Council names its corporate members on its own site (psoriasiscouncil.org/about/corporate-members/, checked 2026-09-11). The top tier names AbbVie, Johnson & Johnson, Eli Lilly, Novartis and Takeda. LEO Pharma, UCB, Almirall, Sun Pharma, Amgen, Alumis, Arcutis and Oruka sit below them. Those firms make the drugs this severity rule opens the door to. A wider rule on who qualifies is a wider market for them. The page says nothing about how that money relates to IPC independence.
What this source supports
Supports that IPC dropped the mild, moderate and severe scale. In its place a person is a candidate for topical therapy, or a candidate for systemic therapy. Supports that any one of three criteria is enough to be a candidate for systemic therapy. The first is psoriasis on 10% or more of the body surface. The second is psoriasis on a high-impact site. IPC names those sites as the face, palms, soles, genitalia, scalp and nails. The third is failure of topical therapy. Supports that IPC defines that failure in writing. It is not reaching clear or almost-clear skin after two four-week courses in a row. IPC gives clear or almost-clear as 1% or less body surface, with a physician global assessment of 0 or 1. Supports the source paper. It is Strober B, Ryan C, van de Kerkhof P, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol 2020 Jan;82(1):117-122. Supports that IPC's own June 2025 teaching deck lists payers among the groups it set out to move. That deck also names refusal to pay as a result of the older scale.
What it does not support
Does not set any health plan's coverage rule. This is a professional-society consensus. It is not a regulation and not a plan document. Does not say which systemic treatment follows once a person meets a criterion. It sets no dose, no frequency and no schedule. Does not give the number of experts who voted, the response rate, or their conflict-of-interest disclosures. IPC's own June 2025 deck states the body-surface threshold two ways. Its criteria summary says 10% or more. The slide expanding that criterion says above 10%. Does not establish that a given reader meets a criterion. It predicts nothing about what a plan will decide.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- National Psoriasis FoundationPatient education · Patient education, tier 5Relevant relationship disclosed
- Published
- SteadySkin last checked
What this source can and cannot tell you
Why the independence label says this: The National Psoriasis Foundation names its corporate members on its own site (psoriasis.org/corporate-members/, checked 2026-09-09). They include AbbVie, Johnson & Johnson, Leo Pharma, Lilly, Novartis, UCB, Amgen, Sun Pharma, Arcutis, Bristol Myers Squibb, Takeda, and Alumis. Several of those firms make the drugs step therapy and copay-card rules affect. NPF also lobbies against both practices. This number and its framing come from a group with a stake in the fight, even though NPF says it does not back one drug over another.
What this source supports
Supports that NPF adopted a two-class definition. Mild psoriasis can be managed with topical therapies. Moderate-to-severe psoriasis makes a person a candidate for advanced therapies. Supports its statement that "Moderate-to-severe psoriasis is not determined solely by body surface area (BSA) involvement of 10%." Supports that psoriasis on a high-impact site counts too. NPF gives those sites as the face, scalp, hands, feet, nails or genitals. It says such patients "should also be considered as having 'moderate-to-severe' disease". Supports that the same holds for people who cannot get adequate control from topical therapies. Supports its statement that "People with psoriasis should never be denied advanced care because of outdated measures."
What it does not support
Does not set any health plan's coverage rule and does not bind a payer. Does not name prior authorization, appeals or denial steps. Gives no appeal deadline and no appeal process. Does not say how much topical treatment counts as inadequate control, or over what period. Does not establish that a given reader is a candidate for a named therapy. It predicts nothing about what a plan will decide.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.