Anthem Blue Cross Connecticut MED.00004 Noninvasive Imaging Technologies for the Evaluation of Skin Lesions Form

This document addresses the use of photographic, optical, video, and other imaging technologies for the evaluation of skin lesions.

For other documents addressing skin lesions, please see:

• CG-SURG-90 Mohs Micrographic Surgery
• GENE.00023 Gene Expression Profiling of Melanomas and Cutaneous Squamous Cell Carcinoma

Position Statement

Not Medically Necessary:

Dermatoscopy (also known as dermoscopy, epiluminescence microscopy [ELM], or digital epiluminescence microscopy [DELM], skin surface microscopy, skin videomicroscopy, or incidence light microscopy) using either direct inspection, digitization of images, or computer-assisted analysis is considered not medically necessary in all cases.

Reflectance confocal microscopy for the evaluation of skin lesions is considered not medically necessary in all cases.

Investigational and Not Medically Necessary:

Whole body integumentary photography, including melanomagram, is considered investigational and not medically necessary in all cases.

The following technologies are considered investigational and not medically necessary for the evaluation of skin lesions:

1. Confocal scanning laser microscopy
2. Electrical impedance spectroscopy
3. Elastic scattering spectroscopy
4. Molecular fluorescent imaging
5. Multi-spectral image analysis
6. Multiphoton laser scanning microscopy
7. Optical coherence tomography
8. Photoacoustic microscopy
9. Quantitative infrared imaging
10. Raman spectroscopy
11. Ultrasonography
12. Visual image analysis