Hidradenitis Suppurativa Treatment Denied: How to Appeal

Hidradenitis suppurativa (HS) is one of the most painful, debilitating skin conditions in existence. Recurring abscesses, tunneling sinus tracts, and permanent scarring rob patients of quality of life, yet getting effective treatment covered by insurance is a battle many face. If your insurer denied Humira (adalimumab), Cosentyx (secukinumab), or surgical procedures, this guide will help you build a winning appeal.

Understanding Why HS Denials Happen

Limited approved biologics: Humira is the only FDA-approved biologic specifically for HS, and it was only approved for this indication in 2015. Cosentyx received FDA approval for moderate-to-severe HS in 2023. Before these approvals, and still sometimes today, insurers may misclassify HS treatments as experimental.

Step therapy through TNF inhibitors: Even with Humira and Cosentyx both approved, insurers may require failure on a specific TNF inhibitor before approving the other, or require antibiotics (doxycycline, clindamycin/rifampin combination) and procedural interventions first.

Hurley staging not documented: Insurance reviewers rely on objective staging to justify biologic therapy. If your records don't include Hurley stage documentation, a medical reviewer may downgrade severity.

Cosentyx off-label use in earlier cases: Before the 2023 FDA approval for HS, Cosentyx was used off-label. Appeals for off-label use require additional peer-reviewed literature support.

Hurley Staging: The Key to Your Appeal

Hurley staging is the primary severity classification system for HS:

Hurley Stage I: Solitary or multiple isolated abscesses without sinus tract formation or scarring. Usually managed with topicals and antibiotics.

Hurley Stage II: Recurrent abscesses with sinus tract formation and scarring, involving one or a few widely separated lesions. Oral antibiotics, hormonal therapy (spironolactone), and procedural interventions are standard. Biologic consideration is appropriate when these fail.

Hurley Stage III: Diffuse or near-diffuse involvement of an entire area, with multiple interconnected sinus tracts and abscesses. Biologic therapy is the standard of care. Surgical options including wide excision are also appropriate.

Your appeal letter must explicitly state your Hurley stage and include supporting clinical description — number of lesions, anatomic locations (axilla, groin, inframammary, perianal), presence of draining sinus tracts, and scarring extent.

Building the Case for Humira or Cosentyx

Humira (adalimumab): The FDA approved adalimumab for moderate-to-severe HS (Hurley Stage II or III) in adults with inadequate response to antibiotics. Your appeal should document:

• Duration and doses of oral antibiotic trials (doxycycline, clindamycin/rifampin) with dates and response
• Clinical photographs if available (with patient consent noted)
• Physician attestation of Hurley Stage II or III disease
• Reference to FDA-approved indication

Cosentyx (secukinumab): FDA-approved for adults with moderate-to-severe HS since 2023. If your insurer denies Cosentyx as "not medically necessary" or "investigational," cite the FDA approval date and the SUNSHINE and SUNRISE trial data directly.

Surgical Alternatives and When Insurance Resists

For patients who cannot access biologics, surgical procedures are an important treatment option:

• Deroofing: Unroofing of sinus tracts — effective for localized Stage II disease
• Wide local excision: Removing entire affected areas, appropriate for Stage III — covered by most insurers when medically documented
• Incision and drainage (I&D): Temporary relief; usually covered but not curative

If your insurer is denying both biologics and surgical intervention, cite the HS Foundation clinical guidelines, which outline a stepwise care pathway and explicitly support surgical management for appropriate stages.

TNF Step Therapy Rebuttals

If required to fail a TNF inhibitor (like adalimumab) before accessing secukinumab, document:

• Secondary loss of response to adalimumab (anti-drug antibodies)
• Injection site reactions or serious adverse events
• Contraindications (active TB, demyelinating disease, CHF)
• Clinical rationale for different mechanism of action (IL-17 vs. TNF)

HS Foundation and AAD Resources

The HS Foundation (hs-foundation.org) publishes patient resources and clinical guidelines that can strengthen your appeal. The AAD has also published position statements on biologic access for HS. Reference both organizations in your appeal letter and cite the clinical evidence they provide.

Fight Back With ClaimBack

ClaimBack's dermatology appeal tools include HS-specific templates with Hurley staging documentation, biologic indication citations, and surgical necessity frameworks.

Start your free appeal at ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Common Reasons Insurance Claims Are Denied