MP-02 Benign Skin Lesion Removal Form

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Medical Policy Benign Skin Lesion Removal

Policy Number: MP-02 Current Effective Date: 04/26/2022 Original Effective Date: 01/12/2015 Next Review/Revision Date: 04/26/2024 Plans: QUEST Integration (Medicaid), AlohaCare Advantage Plus Special Needs Plan (SNP Medicare)

1. Purpose 1.1 The purpose of this policy is to define medically necessary indications for the removal of benign or premalignant skin lesions.

2. Policy 2.1 Benign skin lesions are common, and usually do not cause any problems. In those cases, removal is a cosmetic procedure and not covered by AlohaCare. However, if the benign lesion does cause problems, removal is medically necessary.

3. Definition 3.1 Benign skin lesion is a non‐cancerous growth or patch of the skin that does not resemble the area surrounding it.

4. Procedure 4.1 AlohaCare will cover the removal of Molluscum contagiosum, warts, and epidermoid cysts. 4.2 AlohaCare will cover the removal or destruction of actinic keratoses without restrictions based on lesion or patient characteristics. 4.3 AlohaCare will cover the removal of Seborrheic keratosis, Skin tags, Milia, Nevi, and/or other benign skin tumors as medically necessary, if any one or more of criteria a through f are met: a. The lesion has one or more of the following characteristics:
5. Bleeding;
6. Itching;
7. Pain. b. The lesion has physical evidence of inflammation, such as purulence, oozing, edema, or erythema. c. The lesion obstructs an orifice or clinically restricts vision. d. The clinical diagnosis is uncertain, particular where malignancy is a realistic consideration based on lesion appearance, for instance non‐response to conventional treatment, or significant changes in appearance and/or size. However, if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction. e. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy. f. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.

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4.4 Prior Authorization (PA) is not required. Clear documentation of the skin lesion and condition necessitating its removal or destruction, such as physical appearance and other characteristics (i.e. bleeding, itching, pain, repeated trauma, etc.) must be retained in the medical record and made available upon request. A photograph may be acceptable documentation. 4.5 For a patient under 19 years of age, the removal of benign skin lesions that do not meet the above criteria may be considered on a case by case basis.

5. Limitations 5.1 AlohaCare will not cover the removal of benign skin lesions that are asymptomatic and/or do not pose a threat to health or function and are considered cosmetic. 5.2 This policy does not address routine foot care or the treatment of other skin lesions, e.g., ulcers, abscess, malignancies, dermatoses, or psoriasis.

6. Coding Information The following medical codes are relevant codes for diagnosis and procedures for benign skin lesion removal and for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or provider reimbursement. Benign Lesions that may be removed without additional diagnostic criteria (irritation, etc.) ICD10 CM Description A63.0 Venereal wart B07.0 Plantar wart B07.8 Other viral warts B07.9 Viral wart, unspecified B08.1 Molluscum contagiosum D48.5 Neoplasm of uncertain behavior of skin D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin D49.511 Neoplasm of unspecified behavior of right kidney D49.512 Neoplasm of unspecified behavior of left kidney D49.519 Neoplasm of unspecified behavior of unspecified kidney D49.59 Neoplasm of unspecified behavior of other genitourinary organ H02.821 Cysts of right upper eyelid H02.822 Cysts of right lower eyelid H02.824 Cysts of left upper eyelid H02.825 Cysts of left lower eyelid H61.001 Unspecified perichondritis of right external ear H61.002 Unspecified perichondritis of left external ear H61.003 Unspecified perichondritis of external ear, bilateral

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H61.009 Unspecified perichondritis of external ear, unspecified ear H61.011 Acute perichondritis of right external ear H61.012 Acute perichondritis of left external ear H61.013 Acute perichondritis of external ear, bilateral H61.021 Chronic perichondritis of right external ear H61.022 Chronic perichondritis of left external ear H61.023 Chronic perichondritis of external ear, bilateral H61.031 Chondritis of right external ear H61.032 Chondritis of left external ear H61.033 Chondritis of external ear, bilateral L11.0 Acquired keratosis follicularis L28.0 Lichen simplex chronicus L28.1 Prurigo nodularis L56.5 Disseminated superficial actinic porokeratosis (DSAP) L57.0 Actinic keratosis L82.0 Inflamed seborrheic keratosis L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palmaris et plantaris) L85.8 Other specified epidermal thickening L86 Keratoderma in diseases classified elsewhere L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.2 Elastosis perforans serpiginosa L92.8 Other granulomatous disorders of the skin and subcutaneous tissue L98.0 Pyogenic granuloma

Benign Lesions that may be removed only if complications (irritation, etc) ICD10 CM Description D10.0 Benign neoplasm of lip D18.01 Hemangioma of skin and subcutaneous tissue D22.0 Melanocytic nevi of lip D22.111 Melanocytic nevi of right upper eyelid, including canthus D22.112 Melanocytic nevi of right lower eyelid, including canthus D22.121 Melanocytic nevi of left upper eyelid, including canthus

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D22.122 Melanocytic nevi of left lower eyelid, including canthus D22.21 Melanocytic nevi of right ear and external auricular canal D22.22 Melanocytic nevi of left ear and external auricular canal D22.39 Melanocytic nevi of other parts of face D22.4 Melanocytic nevi of scalp and neck D22.5 Melanocytic nevi of trunk D22.61 Melanocytic nevi of right upper limb, including shoulder D22.62 Melanocytic nevi of left upper limb, including shoulder D22.71 Melanocytic nevi of right lower limb, including hip D22.72 Melanocytic nevi of left lower limb, including hip D22.9 Melanocytic nevi, unspecified D23.0 Other benign neoplasm of skin of lip D23.111 Other benign neoplasm of skin of right upper eyelid, including canthus D23.112 Other benign neoplasm of skin of right lower eyelid, including canthus D23.121 Other benign neoplasm of skin of left upper eyelid, including canthus D23.122 Other benign neoplasm of skin of left lower eyelid, including canthus D23.21 Other benign neoplasm of skin of right ear and external auricular canal D23.22 Other benign neoplasm of skin of left ear and external auricular canal D23.39 Other benign neoplasm of skin of other parts of face D23.4 Other benign neoplasm of skin of scalp and neck D23.5 Other benign neoplasm of skin of trunk D23.61 Other benign neoplasm of skin of right upper limb, including shoulder D23.62 Other benign neoplasm of skin of left upper limb, including shoulder D23.70 Other benign neoplasm of skin of unspecified lower limb, including hip D23.71 Other benign neoplasm of skin of right lower limb, including hip D23.72 Other benign neoplasm of skin of left lower limb, including hip D23.9 Other benign neoplasm of skin, unspecified D28.0 Benign neoplasm of vulva D29.0 Benign neoplasm of penis D29.4 Benign neoplasm of scrotum D86.3 Sarcoidosis of skin D86.89 Sarcoidosis of other sites D86.9 Sarcoidosis, unspecified I78.1 Nevus, non-neoplastic

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K64.4 Residual hemorrhoidal skin tags L12.30 Acquired epidermolysis bullosa, unspecified L12.31 Epidermolysis bullosa due to drug L12.8 Other pemphigoid L72.0 Epidermal cyst L72.11 Pilar cyst L72.12 Trichodermal cyst L72.2 Steatocystoma multiplex L72.3 Sebaceous cyst L72.8 Other follicular cysts of the skin and subcutaneous tissue L82.1 Other seborrheic keratosis L85.9 Epidermal thickening, unspecified L87.9 Transepidermal elimination disorder, unspecified L90.5 Scar conditions and fibrosis of skin L90.9 Atrophic disorder of skin, unspecified L91.0 Hypertrophic scar L91.8 Other hypertrophic disorders of the skin L91.9 Hypertrophic disorder of the skin, unspecified L94.9 Localized connective tissue disorder, unspecified Q17.0 Accessory auricle Q81.0 Epidermolysis bullosa simplex Q81.1 Epidermolysis bullosa letalis Q81.2 Epidermolysis bullosa dystrophica Q81.8 Other epidermolysis bullosa Q81.9 Epidermolysis bullosa, unspecified Q82.8 Other specified congenital malformations of skin

Additional diagnosis that must be present to document complication for removal of above lesions ICD10‐CM Description B78.1 Cutaneous strongyloidiasis D48.5 Neoplasm of uncertain behavior of skin D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin E83.2 Disorders of zinc metabolism K12.2 Cellulitis and abscess of mouth

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L02.01 Cutaneous abscess of face L02.11 Cutaneous abscess of neck L02.211 Cutaneous abscess of abdominal wall L02.212 Cutaneous abscess of back [any part, except buttock] L02.213 Cutaneous abscess of chest wall L02.214 Cutaneous abscess of groin L02.215 Cutaneous abscess of perineum L02.216 Cutaneous abscess of umbilicus L02.31 Cutaneous abscess of buttock L02.411 Cutaneous abscess of right axilla L02.412 Cutaneous abscess of left axilla L02.413 Cutaneous abscess of right upper limb L02.414 Cutaneous abscess of left upper limb L02.415 Cutaneous abscess of right lower limb L02.416 Cutaneous abscess of left lower limb L02.511 Cutaneous abscess of right hand L02.512 Cutaneous abscess of left hand L02.611 Cutaneous abscess of right foot L02.612 Cutaneous abscess of left foot L02.811 Cutaneous abscess of head [any part, except face] L02.818 Cutaneous abscess of other sites L03.111 Cellulitis of right axilla L03.112 Cellulitis of left axilla L03.113 Cellulitis of right upper limb L03.114 Cellulitis of left upper limb L03.115 Cellulitis of right lower limb L03.116 Cellulitis of left lower limb L03.121 Acute lymphangitis of right axilla L03.122 Acute lymphangitis of left axilla L03.123 Acute lymphangitis of right upper limb L03.124 Acute lymphangitis of left upper limb L03.125 Acute lymphangitis of right lower limb L03.126 Acute lymphangitis of left lower limb L03.211 Cellulitis of face L03.212 Acute lymphangitis of face L03.221 Cellulitis of neck

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L03.222 Acute lymphangitis of neck L03.311 Cellulitis of abdominal wall L03.312 Cellulitis of back [any part except buttock] L03.313 Cellulitis of chest wall L03.314 Cellulitis of groin L03.315 Cellulitis of perineum L03.316 Cellulitis of umbilicus L03.317 Cellulitis of buttock L03.321 Acute lymphangitis of abdominal wall L03.322 Acute lymphangitis of back [any part except buttock] L03.323 Acute lymphangitis of chest wall L03.324 Acute lymphangitis of groin L03.325 Acute lymphangitis of perineum L03.326 Acute lymphangitis of umbilicus L03.327 Acute lymphangitis of buttock L03.811 Cellulitis of head [any part, except face] L03.818 Cellulitis of other sites L03.891 Acute lymphangitis of head [any part, except face] L03.898 Acute lymphangitis of other sites L08.82 Omphalitis not of newborn L08.89 Other specified local infections of the skin and subcutaneous tissue L08.9 Local infection of the skin and subcutaneous tissue, unspecified L26 Exfoliative dermatitis L29.9 Pruritus, unspecified L30.4 Erythema intertrigo L53.8 Other specified erythematous conditions L53.9 Erythematous condition, unspecified L54 Erythema in diseases classified elsewhere L92.0 Granuloma annulare L95.1 Erythema elevatum diutinum L98.2 Febrile neutrophilic dermatosis [Sweet] L98.3 Eosinophilic cellulitis [Wells] R20.0 Anesthesia of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation

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R58 Hemorrhage, not elsewhere classified

Malignant lesions that may be removed using procedures CPT 11300-11313 only ICD10‐CM Description C4A.0 Merkel cell carcinoma of lip C4A.111 Merkel cell carcinoma of right upper eyelid, including canthus C4A.112 Merkel cell carcinoma of right lower eyelid, including canthus C4A.121 Merkel cell carcinoma of left upper eyelid, including canthus C4A.122 Merkel cell carcinoma of left lower eyelid, including canthus C4A.21 Merkel cell carcinoma of right ear and external auricular canal C4A.22 Merkel cell carcinoma of left ear and external auricular canal C4A.31 Merkel cell carcinoma of nose C4A.39 Merkel cell carcinoma of other parts of face C4A.4 Merkel cell carcinoma of scalp and neck C4A.51 Merkel cell carcinoma of anal skin C4A.52 Merkel cell carcinoma of skin of breast C4A.59 Merkel cell carcinoma of other part of trunk C4A.61 Merkel cell carcinoma of right upper limb, including shoulder C4A.62 Merkel cell carcinoma of left upper limb, including shoulder C4A.71 Merkel cell carcinoma of right lower limb, including hip C4A.72 Merkel cell carcinoma of left lower limb, including hip C4A.8 Merkel cell carcinoma of overlapping sites C4A.9 Merkel cell carcinoma, unspecified C44.00 Unspecified malignant neoplasm of skin of lip C44.01 Basal cell carcinoma of skin of lip C44.02 Squamous cell carcinoma of skin of lip C44.09 Other specified malignant neoplasm of skin of lip C44.101 Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including canthus C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus

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C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus C44.202 Unspecified malignant neoplasm of skin of right ear and external auricular canal C44.209 Unspecified malignant neoplasm of skin of left ear and external auricular canal C44.212 Basal cell carcinoma of skin of right ear and external auricular canal C44.219 Basal cell carcinoma of skin of left ear and external auricular canal C44.222 Squamous cell carcinoma of skin of right ear and external auricular canal C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal C44.291 Other specified malignant neoplasm of skin of unspecified ear and external auricular canal C44.292 Other specified malignant neoplasm of skin of right ear and external auricular canal C44.299 Other specified malignant neoplasm of skin of left ear and external auricular canal C44.300 Unspecified malignant neoplasm of skin of unspecified part of face C44.301 Unspecified malignant neoplasm of skin of nose C44.309 Unspecified malignant neoplasm of skin of other parts of face C44.310 Basal cell carcinoma of skin of unspecified parts of face C44.311 Basal cell carcinoma of skin of nose C44.319 Basal cell carcinoma of skin of other parts of face C44.320 Squamous cell carcinoma of skin of unspecified parts of face C44.321 Squamous cell carcinoma of skin of nose C44.329 Squamous cell carcinoma of skin of other parts of face C44.390 Other specified malignant neoplasm of skin of unspecified parts of face C44.391 Other specified malignant neoplasm of skin of nose C44.399 Other specified malignant neoplasm of skin of other parts of face C44.40 Unspecified malignant neoplasm of skin of scalp and neck C44.41 Basal cell carcinoma of skin of scalp and neck C44.42 Squamous cell carcinoma of skin of scalp and neck C44.49 Other specified malignant neoplasm of skin of scalp and neck C44.500 Unspecified malignant neoplasm of anal skin C44.501 Unspecified malignant neoplasm of skin of breast C44.509 Unspecified malignant neoplasm of skin of other part of trunk C44.510 Basal cell carcinoma of anal skin C44.511 Basal cell carcinoma of skin of breast C44.519 Basal cell carcinoma of skin of other part of trunk C44.520 Squamous cell carcinoma of anal skin C44.521 Squamous cell carcinoma of skin of breast C44.529 Squamous cell carcinoma of skin of other part of trunk C44.590 Other specified malignant neoplasm of anal skin C44.591 Other specified malignant neoplasm of skin of breast C44.599 Other specified malignant neoplasm of skin of other part of trunk C44.601 Unspecified malignant neoplasm of skin of unspecified upper limb, including shoulder C44.602 Unspecified malignant neoplasm of skin of right upper limb, including shoulder

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C44.609 Unspecified malignant neoplasm of skin of left upper limb, including shoulder C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder C44.619 Basal cell carcinoma of skin of left upper limb, including shoulder C44.622 Squamous cell carcinoma of skin of right upper limb, including shoulder C44.629 Squamous cell carcinoma of skin of left upper limb, including shoulder C44.691 Other specified malignant neoplasm of skin of unspecified upper limb, including shoulder C44.692 Other specified malignant neoplasm of skin of right upper limb, including shoulder C44.699 Other specified malignant neoplasm of skin of left upper limb, including shoulder C44.701 Unspecified malignant neoplasm of skin of unspecified lower limb, including hip C44.702 Unspecified malignant neoplasm of skin of right lower limb, including hip C44.709 Unspecified malignant neoplasm of skin of left lower limb, including hip C44.712 Basal cell carcinoma of skin of right lower limb, including hip C44.719 Basal cell carcinoma of skin of left lower limb, including hip C44.722 Squamous cell carcinoma of skin of right lower limb, including hip C44.729 Squamous cell carcinoma of skin of left lower limb, including hip C44.791 Other specified malignant neoplasm of skin of unspecified lower limb, including hip C44.792 Other specified malignant neoplasm of skin of right lower limb, including hip C44.799 Other specified malignant neoplasm of skin of left lower limb, including hip C44.80 Unspecified malignant neoplasm of overlapping sites of skin C44.81 Basal cell carcinoma of overlapping sites of skin C44.82 Squamous cell carcinoma of overlapping sites of skin

CPT Description 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (list separately in addition to code for primary procedure) 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 11302 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 11303 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm 11305 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

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11306 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm 11307 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm 11308 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm 11310 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 11311 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm 11312 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm 11313 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm 11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 2.1 to 3.0 cm 11404 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm 11406 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm 11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11421 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm 11422 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm 11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

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11424 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm 11426 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm 11440 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less 11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm 11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm 11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm 11444 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm 11446 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm 17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion 17003 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) 17004 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions 17110 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 17111 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions 54050- 54065 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle) 56501 - 56515 Destruction of lesion(s), vulva 57061 - 57065 Destruction of vaginal lesion(s) 64788 Excision of neurofibroma or neurolemmoma; cutaneous nerve

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64790 Excision of neurofibroma or neurolemmoma; major peripheral nerve 64792 Excision of neurofibroma or neurolemmoma; extensive (including malignant type)

7. References/Resources 7.1 Centers for Medicare and Medicaid Services Local Coverage determination (LCD) (L34233) Benign Skin Lesion Removal https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=34233&ver=26&Date=10%2f01%2f2019&DocID=L34233&SearchType=Adva nced&bc=KAAAABAAAAAA& 7.2 Centers for Medicare and Medicaid Services National Coverage Determination (NCD) for Treatment of Actinic Keratosis (250.4) https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=129&ncdver=1&DocID=250.4&SearchType=Advanced&bc=IAAAABAAAAA A& 7.3 Diagnosing Common Benign Skin Tumors, Higgins J, Maher M, Douglas M, American Family Physician, Oct 2015 https://www.aafp.org/afp/2015/1001/p601.html 7.4 Are All Seborrheic Keratoses Benign? Review of the Typical Lesion and Its Variants, Noiles K, Vender R, Journal of Cutaneous Medicine & Surgery Sept, 2008 https://journals.sagepub.com/doi/full/10.2310/7750.2008.07096?url_ver=Z39.88- 2003&rfrid=ori%3Arid%3Acrossref.org&rfrdat=cr_pub%3Dpubmed 7.5 Benign and Premalignant Skin Lesions, Lee E, Nehal K, Disa J, Plastic and Reconstructive Surgery. 125(5):188e-198e, May 2010. https://journals.lww.com/plasreconsurg/pages/results.aspx?txtKeywords=benign+and+premalignant+s kin+lesions 7.6 Treatment Options for Actinic Keratoses, Mcintyre W, Downs M, Bedwell S, Am Fam Physician. 2007 Sep 1;76(5):667-671 https://www.aafp.org/afp/2007/0901/p667.html 7.7 Management of external genital warts, Karnes J, Usatine R, Am Fam Physician. 2014 Sep 1;90(5):312-8 https://www.aafp.org/afp/2014/0901/p312.html 7.8 Interventions for Molluscum Contagiosum, Clinical Question, Am Fam Physician. 2006 Nov 1;74(9):1504 https://www.aafp.org/afp/2006/1101/p1504.html

8. Review/Revision History 08/05/2015, added Criterion 2.h for wart removals. 06/01/2017, added Criterion 3. 10/2017, removed PA requirement. 9/2019 editorial changes, updated references, removed hidradenitis, added neurofibromas, updated coding 04/26/2024 - Retired