Anthem Blue Cross Connecticut CG-SURG-37 Destruction of Pre-Malignant Skin Lesions Form

Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-37 Destruction of Pre-Malignant Skin Lesions Form



Destruction of Actinic Keratosis

Indications

(699063) Is the destruction method one of the following: laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettement? 
(699064) Has actinic keratosis been diagnosed in the patient? 

Destruction of Lentigo Maligna

Indications

(699065) Is the destruction method one of the following: laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettement? 
(699066) Has lentigo maligna been diagnosed in the patient? 

Destruction of Squamous Cell Carcinoma in Situ (Bowen’s Disease)

Indications

(699067) Is the destruction method one of the following: laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettement? 
(699068) Has squamous cell carcinoma in situ (Bowen’s disease) been diagnosed in the patient? 

Destruction of Non-Pre-Malignant Skin Lesions

Notes: Coverage for the destruction of these lesions is not provided as they are not pre-malignant according to the document.

Indications

(699069) Is the skin lesion to be destroyed any of the following non-pre-malignant types: acrochordons (skin tags), cherry angioma, dermatofibroma, hemangioma (superficial or deep), neurofibroma, nevus flammeus (port-wine stain), nevus simplex, pyogenic granuloma, seborrheic keratosis, telangiectasia, verruca vulgaris (warts)? 

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



CG-SURG-37 Destruction of Pre-Malignant Skin Lesions

Subject:

Description

This document addresses destruction of pre-malignant lesions using laser surgery, electrosurgery, cryosurgery, chemosurgery, and other local destruction techniques.

Note: This document does not address the following:

  • Benign or malignant skin lesions.
  • Laser skin resurfacing or surgical excision.
  • Lesions which are pre-malignant, but which are not removed using local destruction techniques, for example Nevus Sebaceous of Jadassohn or Giant Blue Nevus. Such lesions are not included in the list of pre-malignant conditions.

Note: Please see the following related document for additional information:

  • ANC.00007 Cosmetic and Reconstructive Services: Skin Related

Clinical Indications

Medically Necessary:

Destruction (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of pre-malignant skin lesions as defined below is considered medically necessary.

Pre-malignant skin lesions include but are not limited to the following:

  • Actinic keratosis
  • Lentigo maligna
  • Squamous cell carcinoma in situ (Bowen’s disease)

Skin lesions which do not qualify as pre-malignant include but are not limited to the following:

  • Acrochordons (skin tags)
  • Cherry angioma
  • Dermatofibroma
  • Hemangioma (superficial or deep)
  • Neurofibroma
  • Nevus flammeus (port-wine stain)
  • Nevus simplex
  • Pyogenic granuloma
  • Seborrheic keratosis
  • Telangiectasia
  • Verruca vulgaris (warts)