Benign skin lesions are common in the elderly and are sometimes removed at the patient's request. Removal of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic, and as such, are not covered. This policy describes the medical conditions for which skin lesion removal using one of the services listed in the CPT section (shaving, removal, destruction) would be medically necessary and would therefore not be excluded.

The removal of any malignant lesion is medically necessary.

There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts and viral warts is medically appropriate. The removal of these will be considered medically necessary and not cosmetic if one or more of the following conditions are present and clearly documented in the medical record:

• The lesion has one or more of the following characteristics:
  
  
  • Bleeding.
  • Persistent or intense itching.
  • Pain.
    
    
• The lesion has physical evidence of inflammation (purulence, oozing, edema, erythema, etc.)
  
  
• The lesion obstructs an orifice or clinically restricts vision.
  
  
• There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesional appearance, such as increased rate of growth and/or color changes.
  
  
• The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.
  
  
• Wart destruction will be covered if it falls under one of the conditions of the first five bullets above. In addition, because warts are a viral infection of the skin, wart destruction will be covered when any one of the following clinical circumstances is present:
  
  
  • Periocular warts associated with chronic recurrent conjunctivitis though secondary to lesional virus shedding
  • Warts of recent origin in immunosuppressed patients
    
    
• Lesions in sensitive anatomic locations that are non-problematic do not qualify for removal coverage on the basis of location alone.

• The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.
  
  
• The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.
  
  
• Office visits will be covered when the diagnosis of a benign skin lesion(s) is made, even if the removal of a particular lesion(s) is not medically indicated and is therefore not done.

Reasons for Noncoverage

Lesions that are removed that do not meet the criteria in the medical policy will be denied as not medically necessary.  A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Documentation Requirements

• All services billed must have the appropriate medical record documentation supporting the medical necessity of the service. It is not necessary to submit documentation with claims. However, documentation for further clarification of medical necessity may be requested at a later time.
• When using the diagnosis code for inflamed seborrheic keratosis, the medical records should reference a patient’s complaint or a physician’s physical findings.
• In most situations, a separate Evaluation and Management (E/M) service on the same day dermatologic surgery is performed may not be covered unless significant and separately identifiable medical services were rendered and clearly documented in the patient’s medical record. Check the Medicare Physician Fee Schedule Database (MPFSDB) for the codes where the global policy would be applied. Use modifier 25 appended to the appropriate visit code to indicate that the patient’s condition required a significant, separately identifiable visit service in addition to the procedure that was performed.

Provider News

04/2012, Medicare Advantage issues new removal of benign and malignant skin lesions policy

Covered Diagnosis Codes

The following is limited coverage for CPT/HCPCS codes 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 17000, 17003, 17004, 17110 and 17111:

*Effective 10/1/2011

**Effective 10/1/2011, codes 173.0, 173.1, 173.2, 173.3, 173.4, 173.5, 173.6, 173.7, and 173.8 were deleted.