Treatment of Malignant Skin Lesions

Policy ID: S-46-024

Section: Surgery

Effective Date: January 01, 2019

Revised Date: November 21, 2022

Revision Effective Date: January 02, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Mohs Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissue of the skin.

Photodynamic therapy (PDT) is a medical procedure that involves the administration of a photosensitizing drug and subsequent exposure of tumor cells to a non-thermal laser light source to induce cellular damage. Photo-activation of the drug creates a cytotoxic reaction within the cells that destroys dysplastic lesions; the cytotoxic effect is dependent on light and oxygen.

Criteria

MMS is primarily used to treat basal and squamous cell carcinomas, but can be used to treat less common tumors including but not limited to melanoma. MMS may be considered medically necessary for any ONE of the following indications:

When performed in anatomic areas with high-risk recurrences of cancer; or
Recurrent or incomplete excised malignant lesions, regardless of anatomic area; or
Tumor occurring in previously irradiated skin areas of any anatomic area; or
Cancer displaying *aggressive behavior or rapid growth in any anatomic area; or
Cancer with ill-defined borders; or
Malignant lesions in immunosuppressed individuals; or
Tumors with high-risk metastasis; or
Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); or
Exceptionally large size lesions (2.0 cm or greater) in any anatomic region.

*Aggressive behavior must include ANY ONE of the following histologic characteristics:

Sclerotic; or
Morpheaform; or
Fibrosing; or
Metatypical/Infiltrative/Spikey shaped cells groups; or
Perineural or perivascular involvement; or
Nuclear pleomorphism; or
High mitotic activity; or
Superficial multicentric.

MMS not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

17311

17312

17313

17314

17315

Dermatological applications of Photodynamic therapy (PDT) may be considered medically necessary for ANY of the following:

Superficial basal cell skin cancer only when surgery and radiation are contraindicated; or
Bowen’s disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated.

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

96567

96573

96574

J7308

J7309

J7345

Diagnosis Codes

Covered diagnosis codes for procedure codes 17311, 17312, 17313, 17314 and 17315.

C00.0

C00.1

C00.2

C00.3

C00.4

C00.5

C00.6

C00.8

C00.9

C43.0

C43.10

C43.111

C43.112

C43.121

C43.122

C43.20

C43.21

C43.22

C43.30

C43.31

C43.39

C43.4

C43.51

C43.52

C43.59

C43.60

C43.61

C43.62

C43.70

C43.71

C43.72

C43.8

C43.9

C44.00

C44.01

C44.02

C44.09

C44.101

C44.1021

C44.1022

C44.1091

C44.1092

C44.111

C44.1121

C44.1122

C44.1191

C44.1192

C44.121

C44.1221

C44.1222

C44.1291

C44.1292

C44.191

C44.1921

C44.1922

C44.1991

C44.1992

C44.201

C44.202

C44.209

C44.211

C44.212

C44.219

C44.221

C44.222

C44.229

C44.291

C44.292

C44.299

C44.300

C44.301

C44.309

C44.310

C44.311

C44.319

C44.320

C44.321

C44.329

C44.390

C44.391

C44.399

C44.40

C44.41

C44.42

C44.49

C44.500

C44.501

C44.509

C44.510

C44.511

C44.519

C44.520

C44.521

C44.529

C44.590

C44.591

C44.599

C44.601

C44.602

C44.609

C44.611

C44.612

C44.619

C44.621

C44.622

C44.629

C44.691

C44.692

C44.699

C44.701

C44.702

C44.709

C44.711

C44.712

C44.719

C44.721

C44.722

C44.729

C44.791

C44.792

C44.799

C44.80

C44.81

C44.82

C44.89

C44.90

C44.91

C44.92

C44.99

C4A.0

C4A.10

C4A.11

C4A.12

C4A.20

C4A.21

C4A.22

C4A.30

C4A.31

C4A.39

C4A.4

C4A.51

C4A.52

C4A.59

C4A.60

C4A.61

C4A.62

C4A.70

C4A.71

C4A.72

C4A.8

C4A.9

C51.0

C51.1

C51.2

C51.8

C51.9

C52

C57.7

C57.8

C57.9

C60.0

C60.1

C60.2

C60.8

C60.9

C63.00

C63.01

C63.02

C63.10

C63.11

C63.12

C63.2

C63.7

C63.8

C63.9

C76.0

C76.40

C76.41

C76.42

C76.8

C7B.1

D03.0

D03.10

D03.111

D03.112

D03.121

D03.122

D03.20

D03.21

D03.22

D03.30

D03.39

D03.4

D03.51

D03.52

D03.59

D03.60

D03.61

D03.62

D03.70

D03.71

D03.72

D03.8

D03.9

D04.0

D04.10

D04.111

D04.112

D04.121

D04.122

D04.20

D04.21

D04.22

D04.30

D04.39

D04.4

D04.5

D04.60

D04.61

D04.62

D04.70

D04.71

D04.72

D04.8

D04.9

D07.1

D07.2

D07.30

D07.39

D07.4

D07.5

D07.60

D07.61

D07.69

D48.5

Covered diagnosis codes for procedure codes 96567, 96573, 96574, J7308, J7309, and J7345

D04.0

D04.4

D04.5

D04.8

D04.9

D04.10

D04.111

D04.112

D04.121

D04.122

D04.20

D04.21

D04.22

D04.30

D04.39

D04.60

D04.61

D04.62

D04.70

D04.71

D04.72

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 Annual Review-updated language.

Internal Medical Policy Committee 7-22-2021 Coding update;

Removed procedure codes 88331 & 88332

Internal Medical Policy Committee 1-20-2022 Revision

Updated clarifying language; and
Added statement "Covered diagnosis codes for Procedure codes 96567, 96573, 96574, J7308, J7309, and J7345"; and
Added Diagnosis Codes: D04.0; D04.4; D04.5; D04.8; D04.9; D04.10; D04.111; D04.112; D04.121; D04.122; D04.20; D04.21; D04.22; D04.30; D04.39; D04.60; D04.61; D04.62; D04.70; D04.71; and D04.72

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

Updated with minor wording changes.

Internal Medical Policy Committee 11-15-2023 Annual Review - no changes in criteria

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-46-023

Section: Surgery

Effective Date: January 01, 2019

Revised Date: December 08, 2021

Revision Effective Date: March 07, 2022

Last Reviewed: January 20, 2022

Archived Date: January 01, 2023

Applies To: Commercial and Medicaid Expansion

Description

Mohs Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissue of the skin.

Criteria

MMS is primarily used to treat basal and squamous cell carcinomas but can be used to treat less common tumors including but not limited to melanoma. MMS may be considered medically necessary for any ONE of the following indications:

When performed in anatomic areas with high-risk recurrences of cancer; or
Recurrent or incomplete excised malignant lesions, regardless of anatomic area; or
Tumor occurring in previously irradiated skin areas of any anatomic area; or
Cancer displaying *aggressive behavior or rapid growth in any anatomic area; or
Cancer with ill-defined borders; or
Malignant lesions in immunosuppressed individuals, or
Tumors with high-risk metastasis; or
Areas of important tissue preservation (ears, face, feet, hands, genitalia, and perianal); or
Exceptionally large size lesions (2.0 cm or greater) in any anatomic region.

*Aggressive behavior must include ANY ONE of the following histologic characteristics:

Sclerotic
Morpheaform
Fibrosing
Metatypical/Infiltrative/Spikey shaped cells groups
Perineural or perivascular involvement
Nuclear pleomorphism
High mitotic activity
Superficial multicentric

MMS not meeting the criteria as indicated in this policy is considered not medically necessary.

Dermatological applications of Photodynamic therapy (PDT) may be considered medically necessary for ANY of the following:

Superficial basal cell skin cancer only when surgery and radiation are contraindicated; or
Bowen’s disease (squamous cell carcinoma in situ) only when surgery and radiation are contraindicated.

Procedure Codes

96567

96573

96574

J7308

J7309

J7345

Diagnosis Codes

Covered diagnosis codes for procedure codes 17311, 17312, 17313, 17314 and 17315.

C00.0

C00.1

C00.2

C00.3

C00.4

C00.5

C00.6

C00.8

C00.9

C43.0

C43.10

C43.111

C43.112

C43.121

C43.122

C43.20

C43.21

C43.22

C43.30

C43.31

C43.39

C43.4

C43.51

C43.52

C43.59

C43.60

C43.61

C43.62

C43.70

C43.71

C43.72

C43.8

C43.9

C44.00

C44.01

C44.02

C44.09

C44.101

C44.1021

C44.1022

C44.1091

C44.1092

C44.111

C44.1121

C44.1122

C44.1191

C44.1192

C44.121

C44.1221

C44.1222

C44.1291

C44.1292

C44.191

C44.1921

C44.1922

C44.1991

C44.1992

C44.201

C44.202

C44.209

C44.211

C44.212

C44.219

C44.221

C44.222

C44.229

C44.291

C44.292

C44.299

C44.300

C44.301

C44.309

C44.310

C44.311

C44.319

C44.320

C44.321

C44.329

C44.390

C44.391

C44.399

C44.40

C44.41

C44.42

C44.49

C44.500

C44.501

C44.509

C44.510

C44.511

C44.519

C44.520

C44.521

C44.529

C44.590

C44.591

C44.599

C44.601

C44.602

C44.609

C44.611

C44.612

C44.619

C44.621

C44.622

C44.629

C44.691

C44.692

C44.699

C44.701

C44.702

C44.709

C44.711

C44.712

C44.719

C44.721

C44.722

C44.729

C44.791

C44.792

C44.799

C44.80

C44.81

C44.82

C44.89

C44.90

C44.91

C44.92

C44.99

C4A.0

C4A.10

C4A.11

C4A.12

C4A.20

C4A.21

C4A.22

C4A.30

C4A.31

C4A.39

C4A.4

C4A.51

C4A.52

C4A.59

C4A.60

C4A.61

C4A.62

C4A.70

C4A.71

C4A.72

C4A.8

C4A.9

C51.0

C51.1

C51.2

C51.8

C51.9

C52

C57.7

C57.8

C57.9

C60.0

C60.1

C60.2

C60.8

C60.9

C63.00

C63.01

C63.02

C63.10

C63.11

C63.12

C63.2

C63.7

C63.8

C63.9

C76.0

C76.40

C76.41

C76.42

C76.8

C7B.1

D03.0

D03.10

D03.111

D03.112

D03.121

D03.122

D03.20

D03.21

D03.22

D03.30

D03.39

D03.4

D03.51

D03.52

D03.59

D03.60

D03.61

D03.62

D03.70

D03.71

D03.72

D03.8

D03.9

D04.0

D04.10

D04.111

D04.112

D04.121

D04.122

D04.20

D04.21

D04.22

D04.30

D04.39

D04.4

D04.5

D04.60

D04.61

D04.62

D04.70

D04.71

D04.72

D04.8

D04.9

D07.1

D07.2

D07.30

D07.39

D07.4

D07.5

D07.60

D07.61

D07.69

D48.5

Covered diagnosis codes for procedure codes 96567, 96573, 96574, J7308, J7309, and J7345

D04.0

D04.4

D04.5

D04.8

D04.9

D04.10

D04.111

D04.112

D04.121

D04.122

D04.20

D04.21

D04.22

D04.30

D04.39

D04.60

D04.61

D04.62

D04.70

D04.71

D04.72

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-20 Annual Review-updated language.

Internal Medical Policy Committee 7-22-2021 Coding update; Removed procedure codes 88331 & 88332

Internal Medical Policy Committee 1-20-2022 Revision – updated clarifying language, Added statement “Covered diagnosis codes for Procedure codes 96567, 96573, 96574, J7308, J7309, and J7345”

Added Diagnosis Codes: D04.0; D04.4; D04.5; D04.8; D04.9; D04.10; D04.111; D04.112; D04.121; D04.122; D04.20; D04.21; D04.22; D04.30; D04.39; D04.60; D04.61; D04.62; D04.70; D04.71; D04.72

Links

References (PDF)

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search

Treatment of Malignant Skin Lesions

Description

Criteria

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer