Treatment of Benign or Premalignant Skin Conditions

Policy ID: S-36-028

Section: Surgery

Effective Date: September 01, 2019

Revised Date: September 04, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Lesions that cause irritation, pain or bleeding may require removal to alleviate symptoms. Surgical removal is also recommended for any lesion that shows possible signs of malignancy.

Actinic keratoses are sun-induced, premalignant lesions that appear primarily on photo-exposed areas. Actinic cheilitis is a form of actinic keratosis that usually affects the lips. Since many actinic keratoses eventually transform into squamous cell carcinoma, early removal of these lesions can reduce the morbidity and mortality associated with such malignant transformation.

Acne is a common, inflammatory disease of the sebaceous glands characterized by comedones, papules, pustules, inflamed nodules, and superficial pus-filled cysts. Acne occurs when sebum blocks the sebaceous glands and adjacent hair follicles. This blockage allows bacteria to multiply and inflame the blocked hair follicle.

Criteria

Removal of a benign skin lesion (e.g., skin tags, nevus [mole], sebaceous cyst, wart, seborrheic keratosis, or pigmented lesion) may be considered medically necessary when ANY of the following criteria are met:

There is drainage, bleeding, burning, intense itching, or pain associated with the lesion; or
Inflammation, as evidenced by purulence, oozing, edema, erythema, etc.; or
The lesion obstructs a body orifice, or restricts vision; or
There is clinical suspicion of malignancy (e.g., a change in the ABCDEs of skin cancer [asymmetry, border irregularity, color, diameter, evolving or changing in size, shape or color]); or
Due to its anatomical location, the lesion is prone to being recurrently traumatized; or
A prior biopsy suggests or is indicative of lesion malignancy.

Removal of a benign skin lesion (e.g., nevus [mole], sebaceous cyst, wart, seborrheic keratosis, or pigmented lesion) not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure 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

17110

17111

Removal of skin tags that do not meet above criteria are considered cosmetic, and therefore non-covered.

Procedure Codes

11200

11201

For the treatment of Actinic Keratosis or actinic cheilitis ANY of the following treatments may be considered medically necessary:

Cryosurgery (with liquid nitrogen); or
Topical medications (i.e., Topical diclofenac gel, imiquimod cream, ingenol mebutate gel, or 5-fluorouracil [5-FU]); or
Laser therapy; or
Photodynamic therapy (PDT); or
Electrodessication and curettage or full-thickness excision when EITHER of the following criteria is met:
- Progression to squamous cell carcinoma (SCC) is suspected; or
- There has been failure, intolerance or contraindication to treatment using conventional methods (e.g., cryotherapy, topical medication, laser therapy, and/or PDT); or
Medium-depth chemical peels, deep chemical peels, or dermabrasion when BOTH of the following criteria are met:
- There are greater than 10 AK lesions or severe diffuse AK lesions present; and
- There has been failure, intolerance or contraindication to treatment using conventional methods (e.g., cryotherapy, topical medication, or electrodessication and curettage).

Note: Dermal (medium and deep) chemical peels is allowed up to four (4) times in a 12 month period if member has meet above criteria.

Treatment of actinic keratosis or actinic cheilitis treatments not meeting the criteria as indicated in this policy, not medically necessary.

PDT not meeting the criteria as indicated in this policy is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

17000

17003

17004

96567

96573

96574

J7308

J7309

J7345

Epidermal/superficial chemical peels or superficial dermabrasion for the treatment of actinic keratosis is considered cosmetic and therefore, non-covered.

Procedure codes

15788

15792

Surgical treatment of acne may be considered medically necessary for marsupialization, opening, expression, removal of comedones, milia and pustules, incision and drainage.

Surgical treatment of acnenot meeting the criteria as indicated in this policy is/are considered not medically necessary.

Procedure Code

10040

Laser treatment of active acne is considered experimental/investigational. The safety and effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

17110

17111

Diagnosis Codes

Covered diagnosis codes for procedure 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, 17110, 17111

A63.0

B07.0

B07.8

B07.9

B08.1

D10.0

D17.0

D17.1

D17.20

D17.21

D17.22

D17.23

D17.24

D17.30

D17.39

D21.0

D22.0

D22.111

D22.112

D22.121

D22.122

D22.20

D22.21

D22.22

D22.30

D22.39

D22.4

D22.5

D22.61

D22.62

D22.71

D22.72

D23.0

D23.4

D23.5

D23.10

D23.111

D23.112

D23.121

D23.122

D23.20

D23.21

D23.22

D23.30

D23.39

D23.60

D23.61

D23.62

D23.70

D23.71

D23.72

D28.0

D28.1

D37.01

D48.62

D48.5

D48.61

D48.7

H02.821

H02.822

H02.824

I78.1

H02.825

H02.826

K13.21

L72.0

L72.11

L72.12

L82.1

L72.3

L82.0

L98.0

Z85.820

Z85.821

Z85.828

Non-covered Diagnosis Codes for procedures codes 17110 and 17111

L70.0

L70.1

L70.3

L70.4

L70.5

L70.8

L70.9

L73.0

Covered Diagnosis Codes for procedure codes 17000, 17003, 17004, 96567, 96573, 96574, J7308, J7309, J7345

L56.8

L57.0

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 Coding update

Internal Medical Policy Committee 7-22-2020 Coding update

Removed diagnosis code D22.9; and
Added diagnosis codes D22.30, D22.39

Internal Medical Policy Committee 7-22-2021 Annual Review

Internal Medical Policy Committee 1-20-2022 Revision:

Changed Title; and
Updated criteria with clarifying language; and
Added Procedure Codes: 15788; 15792; 17000; 17003; 17004; 17110; 17111; 96567; 96573, 96574, J7308; and
Added Non-covered Diagnosis Codes for Procedure Codes 17110 and 17111 statement; and
Added Diagnosis Codes: L70.0; L70.0; L70.3; L70.4; L70.5; L70.8; L70.9; L73.0; and
Added Covered Diagnosis Codes for Procedure Codes 17000, 17003, 17004, 96567, 96573, 96574, J7308, J7309, J7345 statement; and
Added Diagnosis Code: L57.0.

Internal Medical Policy Committee 11-29-2022 Revision with Coding update - Effective January 02, 2023

Removed Diagnosis codes D22.2; D22.5; D23.60; D49.2 and
Added Diagnosis code L56.8

Internal Medical Policy Committee 3-23-2023 Coding update - Effective March 23, 2023

Added Diagnosis codes D28.0 and D28.1

Internal Medical Policy Committee 7-26-2023 Revision - Effective September 04, 2023

Added statement: 'Note: Dermal (medium and deep) chemical peels is allowed up to four (4) times in a 12-month period if member has meet above criteria.'

Internal Medical Policy Committee 11-215-2023 Coding - Effective October 01, 2023

Removed diagnosis code D48.1

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-36-027

Section: Surgery

Effective Date: September 01, 2019

Revised Date: July 06, 2023

Revision Effective Date: September 04, 2023

Last Reviewed: July 26, 2023

Archived Date: September 30, 2023

Applies To: Commercial and Medicaid Expansion

Description

Lesions that cause irritation, pain or bleeding may require removal to alleviate symptoms. Surgical removal is also recommended for any lesion that shows possible signs of malignancy.

Criteria

There is drainage, bleeding, burning, intense itching, or pain associated with the lesion; or
Inflammation, as evidenced by purulence, oozing, edema, erythema, etc.; or
The lesion obstructs a body orifice, or restricts vision; or
There is clinical suspicion of malignancy (e.g., a change in the ABCDEs of skin cancer [asymmetry, border irregularity, color, diameter, evolving or changing in size, shape or color]); or
Due to its anatomical location, the lesion is prone to being recurrently traumatized; or
A prior biopsy suggests or is indicative of lesion malignancy.

Procedure 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

17110

17111

Removal of skin tags that do not meet above criteria are considered cosmetic, and therefore non-covered.

Procedure Codes

11200

11201

For the treatment of Actinic Keratosis or actinic cheilitis ANY of the following treatments may be considered medically necessary:

Cryosurgery (with liquid nitrogen); or
Topical medications (i.e., Topical diclofenac gel, imiquimod cream, ingenol mebutate gel, or 5-fluorouracil [5-FU]); or
Laser therapy; or
Photodynamic therapy (PDT); or
Electrodessication and curettage or full-thickness excision when EITHER of the following criteria is met:
- Progression to squamous cell carcinoma (SCC) is suspected; or
- There has been failure, intolerance or contraindication to treatment using conventional methods (e.g., cryotherapy, topical medication, laser therapy, and/or PDT); or
Medium-depth chemical peels, deep chemical peels, or dermabrasion when BOTH of the following criteria are met:
- There are greater than 10 AK lesions or severe diffuse AK lesions present; and
- There has been failure, intolerance or contraindication to treatment using conventional methods (e.g., cryotherapy, topical medication, or electrodessication and curettage).

Note: Dermal (medium and deep) chemical peels is allowed up to four (4) times in a 12 month period if member has meet above criteria.

Treatment of actinic keratosis or actinic cheilitis treatments not meeting the criteria as indicated in this policy, not medically necessary.

Procedure Codes

17000

17003

17004

96567

96573

96574

J7308

J7309

J7345

Epidermal/superficial chemical peels or superficial dermabrasion for the treatment of actinic keratosis is considered cosmetic and therefore, non-covered.

Procedure codes

15788

15792

Surgical treatment of acne may be considered medically necessary for marsupialization, opening, expression, removal of comedones, milia and pustules, incision and drainage.

Surgical treatment of acnenot meeting the criteria as indicated in this policy is/are considered not medically necessary.

Procedure Code

10040

Procedure Codes

17110

17111

Diagnosis Codes

A63.0

B07.0

B07.8

B07.9

B08.1

D10.0

D17.0

D17.1

D17.20

D17.21

D17.22

D17.23

D17.24

D17.30

D17.39

D21.0

D22.0

D22.111

D22.112

D22.121

D22.122

D22.20

D22.21

D22.22

D22.30

D22.39

D22.4

D22.5

D22.61

D22.62

D22.71

D22.72

D23.0

D23.4

D23.5

D23.10

D23.111

D23.112

D23.121

D23.122

D23.20

D23.21

D23.22

D23.30

D23.39

D23.60

D23.61

D23.62

D23.70

D23.71

D23.72

D28.0

D28.1

D37.01

D48.1

D48.62

D48.5

D48.61

D48.7

H02.821

H02.822

H02.824

I78.1

H02.825

H02.826

K13.21

L72.0

L72.11

L72.12

L82.1

L72.3

L82.0

L98.0

Z85.820

Z85.821

Z85.828

Non-covered Diagnosis Codes for procedures codes 17110 and 17111

L70.0

L70.1

L70.3

L70.4

L70.5

L70.8

L70.9

L73.0

Covered Diagnosis Codes for procedure codes 17000, 17003, 17004, 96567, 96573, 96574, J7308, J7309, J7345

L56.8

L57.0

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 Coding update

Internal Medical Policy Committee 7-22-2020 Coding update

Removed diagnosis code D22.9; and
Added diagnosis codes D22.30, D22.39

Internal Medical Policy Committee 7-22-2021 Annual Review

Internal Medical Policy Committee 1-20-2022 Revision:

Changed Title; and
Updated criteria with clarifying language; and
Added Procedure Codes: 15788; 15792; 17000; 17003; 17004; 17110; 17111; 96567; 96573, 96574, J7308; and
Added Non-covered Diagnosis Codes for Procedure Codes 17110 and 17111 statement; and
Added Diagnosis Codes: L70.0; L70.0; L70.3; L70.4; L70.5; L70.8; L70.9; L73.0; and
Added Covered Diagnosis Codes for Procedure Codes 17000, 17003, 17004, 96567, 96573, 96574, J7308, J7309, J7345 statement; and
Added Diagnosis Code: L57.0.

Internal Medical Policy Committee 11-29-2022 Revision with Coding update - Effective January 02, 2023

Removed Diagnosis codes D22.2; D22.5; D23.60; D49.2 and
Added Diagnosis code L56.8

Internal Medical Policy Committee 3-23-2023 Coding update - Effective March 23, 2023

Added Diagnosis codes D28.0 and D28.1

Internal Medical Policy Committee 7-26-2023 Revision - Effective September 04, 2023

Added statement: 'Note: Dermal (medium and deep) chemical peels is allowed up to four (4) times in a 12 month period if member has meet above criteria.'

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