Anthem Blue Cross Connecticut Commercial Clinical Policy

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


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)

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