Listing 13.12 Adult Skin Cancer and Melanoma in 2026

Skin cancer is the most common cancer in the United States. The American Cancer Society projects 105,000 new melanoma diagnoses (61,050 men, 43,950 women) and 8,290 melanoma deaths in 2026. Non-melanoma skin cancers (basal cell carcinoma and squamous cell carcinoma) number 5.4 million annually, though most are small and cured with local excision. Merkel cell carcinoma, cutaneous lymphoma, and other rare skin cancers account for the balance.

SSA Listing 13.12 covers adult skin cancers. The listing focuses on metastatic spread, recurrence, and deep invasion rather than simple size or thickness at the primary site. This matters because most non-melanoma skin cancers (basal cell, common squamous cell) are cured by local excision alone and never approach SSDI territory. Metastatic melanoma, advanced squamous cell with regional spread, and Merkel cell carcinoma all fit within 13.12.

The listing text

Listing 13.12 in current form covers "Skin - sarcoma or carcinoma with metastases to or beyond the regional lymph nodes." The listing evaluates skin cancers of any histology (basal cell carcinoma, squamous cell carcinoma, sarcoma, adnexal carcinoma) with metastatic spread beyond regional nodes.

For melanoma specifically, SSA has additional criteria that qualify based on nodal spread, distant metastases, or recurrence. The functional test is whether the disease has spread beyond the primary site to regional nodes at diagnosis or distant sites, or has recurred after prior treatment.

Paragraph A: Metastases to or beyond regional lymph nodes

Metastases to regional lymph nodes:

• For head/neck cutaneous cancers: cervical lymph nodes (levels I-V), parotid nodes, occipital nodes
• For upper extremity cancers: axillary lymph nodes
• For lower extremity cancers: inguinal and femoral lymph nodes
• For trunk cancers: nearest ipsilateral nodal basin (axillary, inguinal, or both depending on midline crossing)

Metastases beyond regional nodes = distant metastases (stage IV):

• M1a - distant skin, soft tissue, or non-regional nodal mets
• M1b - lung mets
• M1c - non-CNS visceral mets (liver, bone, GI, etc.)
• M1d - CNS mets

Paragraph B: Recurrent disease

Recurrent skin cancer after initial treatment, except for local recurrence at the primary site that is controlled by additional therapy. Regional or distant recurrence qualifies under 13.12B.

Melanoma-specific criteria

Melanoma qualifies when:

• Sentinel node biopsy or completion lymphadenectomy shows positive nodes (stage III disease)
• Distant metastases at any site (stage IV disease)
• Recurrence after prior treatment, except controlled local recurrence at primary site
• In-transit metastases (stage IIIB-IIID depending on other factors)

Stage IIA or IIB melanoma without positive nodes generally does not meet 13.12 automatically but may qualify through RFC analysis for high-risk features (ulceration, high mitotic rate, deep Breslow thickness).

Melanoma subtypes

Cutaneous melanoma (90% of melanoma)

Superficial spreading (60-70% of cutaneous), nodular (15-30%), lentigo maligna (5-15%), acral lentiginous (5-10%, more common in darker skin, arises on palms/soles/nail beds), desmoplastic (1-4%). Standard 8th edition AJCC staging based on Breslow thickness (T), ulceration status, nodal involvement (N), and distant metastases (M).

Uveal melanoma (5-6% of melanoma)

Arises from melanocytes in the choroid, ciliary body, or iris. Biologically distinct from cutaneous melanoma. Does not respond to typical immunotherapy well. About 50% develop distant metastases (predominantly liver). Tebentafusp is the first therapy shown to improve overall survival in metastatic uveal melanoma - restricted to HLA-A*02:01 positive patients (about 45% of US adults).

Mucosal melanoma (1-2% of melanoma)

Arises from melanocytes in mucosal surfaces - sinonasal, oral, esophageal, anorectal, vulvovaginal. Aggressive with poor prognosis. Different molecular profile than cutaneous (less UV signature, more KIT and NRAS mutations, rarely BRAF).

Merkel cell carcinoma

Rare (about 3,000 US cases per year) but aggressive neuroendocrine skin cancer. Associated with Merkel cell polyomavirus (80% of cases) or UV damage. Highly responsive to immunotherapy (avelumab, pembrolizumab). Metastatic Merkel cell carcinoma is on the CAL list.

Diagnostic evidence required

SSA requires objective medical evidence:

• Pathology report from skin biopsy (punch, shave, or excisional) or wide local excision with:
  • Histologic subtype
  • Breslow thickness in mm
  • Ulceration status
  • Mitotic rate per mm2
  • Presence of regression
  • Lymphovascular invasion
  • Perineural invasion
  • Peripheral and deep margin status
• Sentinel lymph node biopsy report if performed (standard for T1b and thicker melanomas)
• Molecular testing:
  • BRAF V600 mutation (50% of cutaneous melanoma, drives targeted therapy eligibility)
  • NRAS mutations (15-20%, no direct targeted therapy but affects prognosis)
  • KIT mutations (higher in mucosal and acral - crizotinib or imatinib may be considered)
  • GNAQ/GNA11 in uveal melanoma
  • HLA-A*02:01 typing for tebentafusp eligibility (uveal)
  • PD-L1 status
  • Tumor mutational burden (TMB)
• Staging imaging: CT chest/abdomen/pelvis, PET-CT, brain MRI (routine for stage III+), lactate dehydrogenase (LDH) as a serum marker (elevated LDH is stage IV M1c prognostic marker)
• Ophthalmologic exam for uveal melanoma with fundus photography and ocular ultrasound

The Compassionate Allowance overlay

Three skin cancer conditions on the CAL list:

• Metastatic melanoma (any distant metastases, stage IV)
• Merkel cell carcinoma with metastases
• Ocular (uveal) melanoma with metastases

Stage III melanoma (regional nodal disease) is not on CAL but still meets 13.12. Non-metastatic Merkel cell carcinoma does not automatically CAL but is often expedited given the aggressive natural history.

Modern treatment residuals for the CDR

The 3-year remission rule under 13.00H1 applies. Melanoma has some of the most dramatic treatment responses in modern oncology, with meaningful long-term survival now possible for stage IV disease. Treatment residuals become the driver of ongoing disability at 3-year CDR.

BRAF/MEK targeted therapy

Dabrafenib + trametinib (Tafinlar + Mekinist), encorafenib + binimetinib (Braftovi + Mektovi), vemurafenib + cobimetinib (Zelboraf + Cotellic) for BRAF V600-mutated melanoma. Common toxicities:

• Fever/pyrexia (30-50% with dabrafenib + trametinib)
• Rash
• Diarrhea
• Fatigue
• Retinal detachment/retinopathy (particularly with MEK inhibitors)
• Cardiac toxicity with LVEF decline (5-10%)
• Squamous cell carcinomas and keratoacanthomas as paradoxical effect (10-20% with BRAF monotherapy, reduced with MEK combination)
• Hepatotoxicity

Anti-PD1 monotherapy (pembrolizumab, nivolumab)

Standard first-line for stage IV melanoma without high tumor burden. Also adjuvant for resected stage IIB, IIC, and III melanoma. Immune-related adverse events at typical checkpoint inhibitor rates (see 13.14 lung article for full profile). Endocrine irAEs (hypothyroidism 10-15%, adrenal insufficiency 2-5%, T1DM under 1%) are almost universally permanent.

Nivolumab + ipilimumab dual immunotherapy

Standard for high-risk stage IV melanoma (CheckMate 067 trial showed 50%+ 5-year survival, historically unheard of). Cumulative irAE rates much higher than monotherapy:

• Grade 3-4 irAE in 55-60% of patients
• Treatment discontinuation for toxicity in 40%
• Colitis 10-15% grade 3+
• Hepatitis 10-15% grade 3+
• Endocrine irAEs 30-40% cumulative (hypothyroidism, hyperthyroidism transitioning to hypothyroidism, hypophysitis with panhypopituitarism, adrenal insufficiency, T1DM)
• Pneumonitis 5-8%
• Nephritis 3-5%

Endocrine irAEs from combination immunotherapy are typically lifelong and qualify under 9.00 endocrine listings at CDR.

Nivolumab + relatlimab (Opdualag) - LAG-3 inhibitor combination

FDA-approved 2022 for stage IV melanoma. Improved PFS over nivolumab monotherapy in RELATIVITY-047 trial with lower toxicity than nivo + ipi. Toxicity profile intermediate between monotherapy and nivo + ipi.

Tebentafusp (Kimmtrak) - uveal melanoma

First therapy shown to improve overall survival in metastatic uveal melanoma. Restricted to HLA-A*02:01 positive patients. Weekly IV infusions with cytokine release syndrome (100% first infusion, decreasing with subsequent), rash, pyrexia, hypotension. Requires stepped dosing schedule with in-hospital first infusions.

Talimogene laherparepvec (T-VEC) - oncolytic virus

Intralesional injection of modified HSV-1 for unresectable stage IIIB, IIIC, or IV M1a melanoma. Local injection site reactions, flu-like symptoms. Rarely used as monotherapy now, more often in combination with checkpoint inhibitors.

Surgical residuals

Wide local excision typically requires 1-2 cm margins for melanoma. Larger excisions on the trunk, extremities, or face may require skin grafting or flap reconstruction. Sentinel node biopsy usually well-tolerated. Completion lymphadenectomy (for positive sentinel, though this is less commonly done post-MSLT-II trial) causes lymphedema in 20-40% of axillary or inguinal dissections.

Worked case examples

Case 1: Marcus, 55, Florida, BRAF V600E metastatic melanoma

Marcus noticed a changing mole on his back in January 2026. Excisional biopsy: 3.2 mm ulcerated superficial spreading melanoma, mitotic rate 6/mm2, no LVI. Sentinel node biopsy: 2 of 3 axillary nodes positive with extranodal extension. Restaging CT: 3 liver lesions and 2 lung nodules. LDH 425 (elevated). Stage IV M1c. BRAF V600E positive, PD-L1 30%.

SSDI application filed February 2026. CAL for metastatic melanoma triggered. Approved 14 days at Florida DDS. Started nivolumab + ipilimumab per CheckMate 067. Achieved partial response at 3 months, ongoing at 12 months. Developed grade 3 colitis at month 4 requiring infliximab, permanent discontinuation of ipilimumab. Continued nivolumab monotherapy. Developed autoimmune hypothyroidism at month 6 (permanent, levothyroxine). At 3-year CDR (2029), no evidence of active melanoma but permanent hypothyroidism and mild residual colitis symptoms continue to support disability findings.

Case 2: Angela, 68, Ohio, HLA-A*02:01+ metastatic uveal melanoma

Angela was diagnosed with choroidal melanoma of the right eye 2020, treated with plaque brachytherapy. Preserved vision. Surveillance MRI in 2026 showed 4 new liver lesions. Liver biopsy: metastatic uveal melanoma. HLA typing: HLA-A*02:01 positive. Elevated LDH.

SSDI application filed May 2026. CAL for ocular melanoma with metastases triggered. Approved 12 days at Ohio DDS. Started tebentafusp weekly with stepped dosing. Grade 2 cytokine release syndrome first 3 infusions, tolerated with premedication. Stable disease at 6 months.

Case 3: Robert, 71, Michigan, Merkel cell carcinoma with regional nodes

Robert developed a rapidly enlarging red-purple nodule on his forehead in March 2026. Punch biopsy: Merkel cell carcinoma with CK20+, TTF-1 negative, chromogranin+, synaptophysin+ neuroendocrine markers. PET-CT: 2 cm parotid node and multiple cervical nodes level II-III involved. No distant disease. Stage IIIB.

SSDI application filed April 2026. Listing 13.12A met (regional nodes). Approved 3 weeks at Michigan DDS. Treated with wide local excision + parotidectomy + neck dissection + adjuvant radiation, then adjuvant avelumab.

What to file with your application

1. Skin biopsy pathology with Breslow thickness, ulceration, mitotic rate
2. Wide local excision pathology (margins)
3. Sentinel node biopsy report
4. Molecular testing (BRAF, NRAS, KIT, HLA-A*02:01 for uveal)
5. Staging imaging (CT, PET-CT, brain MRI)
6. LDH level
7. Oncology consultation notes with stage assignment
8. Current treatment plan and any complications

Related reading

Full section walkthrough: Section 13.00 cancer basics. Companion cancer listings: 13.05 lymphoma, 13.10 breast, 13.14 lung, 13.15 mesothelioma, 13.18 colorectal, 13.24 prostate.

Frequently asked questions

Next steps

If you were diagnosed with metastatic melanoma, stage III melanoma with positive nodes, Merkel cell carcinoma, uveal melanoma, or advanced squamous cell skin cancer, file for SSDI immediately after pathology confirmation. The CAL flag for metastatic disease will accelerate processing.