Subject:
Removal of Benign Skin Lesions
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Skin and subcutaneous tissue lesions are removed by excision, shaving, or any of the various destruction methods (i.e., electrocautery, electrodesiccation, cryosurgery, laser, chemical). The type of removal is generally determined by the treating physician and the technique used will not be a factor in deciding whether or not the procedure is medically necessary. Depending on the purpose for removing the lesion, the specimen may be submitted for histopathology examination. Benign skin and subcutaneous tissue lesions are commonly and are frequently removed at the patient's request to improve appearance.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) considers removal of skin and subcutaneous tissue lesions [e.g., seborrheic keratosis, sebaceous or epidermoid cysts, skin tags, scars, keloids, lipoma, etc.] cosmetic when they do not pose a threat to health and function. These procedures are primarily intended to improve appearance.
II. When one or more of the following conditions is presented and clearly documented on copies of original medical records submitted either hard copy or electronically, removal of benign lesions will considered medically necessary, and not cosmetic:
A. A prior biopsy of the lesion suggests or is indicative of malignancy.
[NOTE: A copy of the original histopathology report is required and must be submitted either hard copy or electronically by the requesting physician.]
B. There is clinical uncertainty of diagnosis of the lesion that has characteristics suggestive of malignancy or precursors to malignancy based on its growth, appearance (size, color change, shape), pigmentation, consistency, etc. as documented by the requesting physician.
[NOTE: It is assumed that the specimen is submitted for histopathology examination when the lesion is removed based on clinical uncertainty of diagnosis.
It is important to distinguish benign acquired pigmented lesions of the skin from dysplastic nevi which may be precursors to or markers for cutaneous melanoma. Most benign acquired pigmented lesions are usually uniformly tan or brown; round with sharp, clear-cut borders; <6 mm in diameter; <40 in number; and generally on sun-exposed surfaces on the skin above the waist but rarely involve the scalp, breasts and buttocks. On the other hand, dysplastic nevi are usually variable mixture of tan-brown, black, or red/pink within a single nevus; irregular borders with pigment fading off into surrounding skin; >6 mm in diameter; often >100 in number; on sun-exposed areas with the back being the most common site.]
C. The lesion has one or more of the following characteristics and is not amenable to medical treatment as documented on copies of original medical records submitted either hard copy or electronically by the requesting physician (i.e., copies of original medical records submitted either hard copy or electronically):
1. bleeding
2. intense itching or burning
3. pain or tenderness
4. undergone recent growth
5. recurrent infection
D. The lesion is in a sensitive anatomical location which interferes with body function (e.g., vision, feeding, breathing) or movement, and/or is subject to recurrent physical trauma, as documented on copies of original medical records submitted either hard copy or electronically by the requesting physician.
E. Removal of the following lesions via any technique is generally considered not cosmetic and thus, medically necessary:
1. Port-wine stains
[Please note that other telangiectasia such as angiomata and hemangiomata are considered cosmetic unless they meet the criteria as stated in the above policy statements II.C and/or II.D. However, these criteria would not be applicable to spider veins since their treatments are cosmetic in nature.]
2. Viral warts/verrucae
F. Surgical treatment of actinic keratoses (e.g., excision, destruction by laser surgery, electrosurgery, cryosurgery, etc.) is not considered cosmetic and thus, it is considered medically necessary.
III. Emotional or psychological distress as the sole indication for removal of the lesion does not constitute medical necessity or appropriateness.
IV. Documentation requirements:
A. The requesting physician must submit either hard copy or electronically copies of original medical records documenting the medical necessity for removal of lesion(s). Documentation must indicate the patient's complaints, detailed objective findings and characteristics of the lesion (especially rate of growth), any functional impairment secondary to the lesion, and clinical history including previous treatments, if any.
B. When the lesion is removed based on results of prior biopsy, the histopathology report is required.
Medicare Coverage:
There is no National Coverage Determination (NCD) for Removal of Benign Skin Lesions. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers.
There are three Local Coverage Determinations applicable to this policy.
For eligibility and coverage, please refer to the below Local Coverage Determinations:
Local Coverage Determinations: (LCD): Removal of Benign Skin Lesions (L34938). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L35090). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Local Coverage Determination (LCD): Routine Foot Care (L35138). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
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.
Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone. A statement of “irritated skin lesion” or “inflamed seborrheic keratosis” will be insufficient justification for lesion removal when used solely to describe a patient’s complaint or the physician’s or non-physician practitioner’s physical findings. It is important to document the patient’s signs and symptoms as well as the physician’s or non-physician practitioner’s physical findings. Drawings or diagrams to describe the precise anatomical location of the lesion are helpful. Documentation of a procedural note, protocol describing indications, diagnosis, and method (or modality) of treatment is advised.
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 or non-physician practitioner’s uncertainty as to the final clinical diagnosis.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Removal of Benign Skin Lesions
Benign Skin Lesions
Cryosurgery, Skin Lesions
Cutaneous Tags
Destruction of Skin Lesions
Electrodesiccation of Skin Lesion
Excision of Skin Lesions
Hemangiomas
Keloids
Laser Treatment for Skin Lesions
Neoplasms, Benign Skin
Port-Wine Stains
Scars
Skin Lesions
Skin Tags
Tags, Skin
Vascular Neoplasms of the Skin
Verrucae
Warts
Spider Veins
References:
1. Sober AJ. Benign Acquired Pigmented Lesions of Skin. Oxford Textbook of Surgery. Oxford University Press, 1994.
2. Robbins SL, Cotran RS, Kumar V. Benign Vascular Neoplasms. Robbins Pathologic Basis of Disease. W.B. Saunders Company, 1991.
3. Novitas Solutions. Local Coverage Determination (LCD): Removal of Benign or Premalignant Skin Lesions (L27527). For services performed on or after 07/11/2008. Available at http://www.novitas-solutions.com/LCDSearchResults/faces/spaces/search/page/lcd.jspx?Jurisdiction=JL&_afrLoop=323197605955000&State=Pennsylvania&_afrWindowMode=0&lcdID=L27527&medicareType=Part+B&_adf.ctrl-state=30ygi07x0_4 (accessed 11/19/14).
4. UpToDate. Overview of benign lesions of the skin. Literature review current through September 2016. Topic last updated November 11, 2015.
5. Goldstein BG, Goldstein AO. Overview of benign lesions of the skin. In: UpToDate: Dellavalle RP, Corona R (Eds), UpToDate, Waltham, MA. (Accessed on September 6, 2017.)
6. Goldstein BG, Goldstein AO. Overview of benign lesions of the skin. In: UpToDate: Dellavalle RP, Corona R (Eds), UpToDate, Waltham, MA. (Accessed on August 9, 2018.)
7. Goldstein BG, Goldstein AO. Overview of benign lesions of the skin. In: UpToDate: Dellavalle RP, Corona R (Eds), UpToDate, Waltham, MA. (Accessed on August 21, 2019.)
8. Hugh JM. Minor dermatologic procedures. In: UpToDate: Dellavalle RP, Corona R (Eds), UpToDate, Waltham, MA. (Accessed on August 21, 2019.)
9. Goldstein BG, Goldstein AO. Overview of benign lesions of the skin. In: UpToDate: Dellavalle RP, Corona R (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
10. Hugh JM. Minor dermatologic procedures. In: UpToDate: Dellavalle RP, Corona R (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
11055
11056
11057
11200
11201
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
17106
17107
17108
17110
17111
17340
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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