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)