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Benign skin lesions are common and removal is frequently requested by the patient to improve appearance.
Benign skin lesions to which the following policy applies are the following seborrheic keratoses; sebaceous (epidermoid) cysts, and viral warts (excluding condyloma acuminatum).
POLICYCosmetic surgery and any complications of cosmetic surgery are not eligible for coverage. This includes any operative procedure or any portion of an operative procedure intended solely to improve physical appearance. Exceptions are those procedures that restore bodily function or correct deformity resulting from disease, trauma or complications of previous non-cosmetic surgery.
The physician has the responsibility to notify the patient in advance that Blue Cross & Blue Shield of Mississippi will not cover cosmetic dermatological surgery and that the subscriber will be liable for the cost of the service. It is strongly advised that the subscriber be provided with a written notification of this fact and that the subscriber, by her/his signature, accepts responsibility for payment. Charges should be clearly stated, as well. Member is also on notice through Policy or Employee booklet.
Seborrheic keratoses, sebaceous (epidermoid) cysts, nevi, papillomas and viral warts (excluding condyloma acuminatum) must be symptomatic or present with objective signs/symptoms as listed below. Otherwise, they are considered to have been removed for cosmetic purposes and, therefore, not medically necessary.
The necessity for removal or biopsy must be documented. One or more of the following conditions must be present in order for their removal to be considered medically necessary:
Medical records maintained by the physician must clearly and unequivocally document the medical necessity for lesion removal(s). Documentation must contain a written description of each surgically treated lesion in terms of location, and physical characteristics.
A record of statement of a non-specific diagnosis such as "skin lesion" with or without documentation of signs and symptoms will not be sufficient justification for lesion removal when used solely to reference a patient's complaint or a physician's physical findings. Similarly, use of ICD-9-CM code 702.11 - "Inflamed seborrheic keratosis" - will be insufficient to justify lesion removal without medical record documentation of the patient's symptoms and physical findings.
When size change is present, documentation of size change is necessary. The documentation that establishes the medical necessity of each service must be maintained with the patient's record.
Removal of benign skin lesions for reasons other than those listed above as medically necessary is considered to be cosmetic and not medically necessary. These reasons include, but are not limited to:
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 lesion excision, (CPT 11400-11446), 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.
Scar removal or revision (surgery or intralesional steroid injection) is considered medically necessary for the following indications when adequate documentation is provided:
Blue Cross & Blue Shield of Mississippi will follow CPT coding guidelines when an evaluation and management service is reported on the same day a dermatological surgical procedure is performed.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Office visits will be covered when the diagnosis of a benign skin lesion(s) is made even if the removal of a particular lesion or lesion(s) is not medically indicated and is therefore not done.
Blue Cross & Blue Shield of Mississippi will not pay for the excision of a benign or premalignant lesion and simple repair of the same lesion. Separate payment for simple repairs (CPT codes 12001 - 12018) will not be made when reported with the CPT codes for the excision of benign or malignant lesions.
Payment for the excision of a benign lesion with a lesion diameter greater than 0.5 cm or the excision of a malignant lesion of any size does not include payment for intermediate or complex repairs. When medically necessary, intermediate repair (CPT 12031-12057) or complex repair (CPT 13100-13152) may be reported separately.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY5/2000: Approved by Medical Policy Advisory Committee (MPAC)
3/27/2002: References to the Master contract deleted
5/2/2002: Type of Service and Place of Service deleted
5/14/2002: Code Reference section updated; ICD-9 diagnosis code 686.1 deleted
10/25/2002: Code Reference section updated; ICD-9 diagnosis codes 757.39 & V16.8 moved to non-covered
11/1/2002: ICD-9 diagnosis code 701.9 added to non-covered
10/18/2005: Code Reference updated; Non-Covered Codes table deleted; CPT-4 codes 11056 and 11057 grouped with 11055 and description revised. CPT-4 codes 17003, 17004, 17110, and 17111 grouped with 17000 and description revised. CPT-4 codes 17106, 17107, 17108, and 17250 added.ICD-9 Diagnosis codes 078.11 added.
9/22/2006: Coding updated. ICD9 2006 revisions added to policy
10/24/2006: Policy reviewed, no changes
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/10/2008: Annual ICD-9 updates effective 10-1-2008 applied
04/07/2014: Policy reviewed; no changes.
09/01/2015: Code Reference section updated for ICD-10.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
Cosmetic and Reconstructive Procedures in Plastic Surgery, published by the American Society of Plastic and Reconstructive Surgeons, Inc., 1989
Dermatology Carrier Medical Directors Workgroup, Upstate New York Medicare Division
Epstein, E. Dermatologic disorders in The Merck Manual, 16th Ed., New Jersey: Merck and Co., Inc., 1992, pp. 2399-2460.
Ho V, McLean DI. Benign epithelial tumors in Dermatology in General Medicine, 4th Ed., McGraw-Hill, Inc., pp. 855-872.
Stone MS, Lynch, PJ. Viral warts in Principles and Practices of Dermatology, Churchill Livingstone, 1990, pp. 119-127.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.