707 Form

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Medical Policy Benign Skin Lesions Table of Contents • Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • Endnotes • Coding Information • References

Policy Number: 707 BCBSA Reference Number: N/A Related Policies
• Plastic Surgery #068
• Optical Diagnostic Devices for Evaluating Skin Lesions Suspected of Malignancy #519 • Ultrasonographic Evaluation of Skin Lesions #303
Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Removal of a benign skin lesion (e.g., nevus/mole, sebaceous cyst (pilar or epidermoid), wart, skin tag, seborrheic keratosis, or pigmented lesion) is considered MEDICALLY NECESSARY when ANY of the following criteria are met:

Suspicious for malignancy
a. There is a clinical suspicion of malignancy.

Pre-malignant a. Known premalignant lesions e.g., actinic keratosis.

Symptomatic as evidenced by any of: a. Pain associated with the lesion b. Intense itching or burning c. Bleeding
d. Recurrent trauma/irritation due to its location (e.g., edges of clothing).

Inflamed as evidenced by any of: a. Discharge/oozing b. Swelling c. Edema d. Erythema
e. Purulence.

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Functional limitation
a. E.g., eyelid lesion that restricts vision, or a lesion that obstructs a body orifice.

Potential risk for infection transmission
a. E.g., warts, molluscum, condyloma.

Removal of benign lesions to improve appearance or for personal preference is considered NOT MEDICALLY NECESSARY.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 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 The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description

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A63.0 Anogenital (venereal) warts B07.0 Plantar wart B07.8 Other viral warts B07.9 Viral wart, unspecified B08.1 Molluscum contagiosum D37.01 Neoplasm of uncertain behavior of lip D37.02 Neoplasm of uncertain behavior of tongue D37.030 Neoplasm of uncertain behavior of the parotid salivary glands D37.031 Neoplasm of uncertain behavior of the sublingual salivary glands D37.032 Neoplasm of uncertain behavior of the submandibular salivary glands D37.039 Neoplasm of uncertain behavior of the major salivary glands, unspecified D37.04 Neoplasm of uncertain behavior of the minor salivary glands D37.05 Neoplasm of uncertain behavior of pharynx D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity D40.0 Neoplasm of uncertain behavior of prostate D40.10 Neoplasm of uncertain behavior of unspecified testis D40.11 Neoplasm of uncertain behavior of right testis D40.12 Neoplasm of uncertain behavior of left testis D40.8 Neoplasm of uncertain behavior of other specified male genital organs D48.1 Neoplasm of uncertain behavior of connective and other soft tissue D48.5 Neoplasm of uncertain behavior of skin L57.0 Actinic keratosis L82.0 Inflamed seborrheic keratosis

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes:

Code 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) 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

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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 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 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 The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: Note: Any diagnosis code from column 1 must be accompanied by any diagnosis code from column 2 to be considered medically necessary. Column 1 Diagnosis code Column 1 Description Column 2 Diagnosis code Column 2 Description A63.0 Anogenital (venereal) warts D69.8 Other specified hemorrhagic conditions B07.0 Plantar wart D69.9 Hemorrhagic condition, unspecified B07.8 Other viral warts H57.10 Ocular pain, unspecified eye

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B07.9 Viral wart, unspecified H57.11 Ocular pain, right eye B08.1 Molluscum contagiosum H57.12 Ocular pain, left eye B35.1 Tinea unguium H57.13 Ocular pain, bilateral B35.2 Tinea manuum L03.011 Cellulitis of right finger B35.3 Tinea pedis L03.012 Cellulitis of left finger B35.4 Tinea corporis L03.019 Cellulitis of unspecified finger B35.6 Tinea cruris L03.021 Acute lymphangitis of right finger B35.8 Other dermatophytoses L03.022 Acute lymphangitis of left finger B35.9 Dermatophytosis, unspecified L03.029 Acute lymphangitis of unspecified finger D10.0 Benign neoplasm of lip L03.031 Cellulitis of right toe D10.39 Benign neoplasm of other parts of mouth L03.032 Cellulitis of left toe D17.0 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck L03.039 Cellulitis of unspecified toe D17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk L03.041 Acute lymphangitis of right toe D17.20 Benign lipomatous neoplasm of skin and subcutaneous tissue of unspecified limb L03.042 Acute lymphangitis of left toe

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D17.21 Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm L03.049 Acute lymphangitis of unspecified toe D17.22 Benign lipomatous neoplasm of skin and subcutaneous tissue of left arm L03.111 Cellulitis of right axilla D17.23 Benign lipomatous neoplasm of skin and subcutaneous tissue of right leg L03.112 Cellulitis of left axilla D17.24 Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg L03.113 Cellulitis of right upper limb D17.30 Benign lipomatous neoplasm of skin and subcutaneous tissue of unspecified sites L03.114 Cellulitis of left upper limb D17.39 Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites L03.115 Cellulitis of right lower limb D17.79 Benign lipomatous neoplasm of other sites L03.116 Cellulitis of left lower limb D17.9 Benign lipomatous neoplasm, unspecified L03.119 Cellulitis of unspecified part of limb D18.01 Hemangioma of skin and subcutaneous tissue L03.121 Acute lymphangitis of right axilla D22.0 Melanocytic nevi of lip L03.122 Acute lymphangitis of left axilla D22.10 Melanocytic nevi of unspecified eyelid, including canthus L03.123 Acute lymphangitis of right upper limb

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D22.111 Melanocytic nevi of right upper eyelid, including canthus L03.124 Acute lymphangitis of left upper limb D22.112 Melanocytic nevi of right lower eyelid, including canthus L03.125 Acute lymphangitis of right lower limb D22.121 Melanocytic nevi of left upper eyelid, including canthus L03.126 Acute lymphangitis of left lower limb D22.122 Melanocytic nevi of left lower eyelid, including canthus L03.129 Acute lymphangitis of unspecified part of limb D22.20 Melanocytic nevi of unspecified ear and external auricular canal L03.211 Cellulitis of face D22.21 Melanocytic nevi of right ear and external auricular canal L03.212 Acute lymphangitis of face D22.22 Melanocytic nevi of left ear and external auricular canal L03.213 Periorbital cellulitis D22.30 Melanocytic nevi of unspecified part of face L03.221 Cellulitis of neck D22.39 Melanocytic nevi of other parts of face L03.222 Acute lymphangitis of neck D22.4 Melanocytic nevi of scalp and neck L03.311 Cellulitis of abdominal wall D22.5 Melanocytic nevi of trunk L03.312 Cellulitis of back [any part except buttock] D22.60 Melanocytic nevi of unspecified upper limb, including shoulder L03.313 Cellulitis of chest wall D22.61 Melanocytic nevi of right upper limb, including shoulder L03.314 Cellulitis of groin

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D22.62 Melanocytic nevi of left upper limb, including shoulder L03.315 Cellulitis of perineum D22.70 Melanocytic nevi of unspecified lower limb, including hip L03.316 Cellulitis of umbilicus D22.71 Melanocytic nevi of right lower limb, including hip L03.317 Cellulitis of buttock D22.72 Melanocytic nevi of left lower limb, including hip L03.319 Cellulitis of trunk, unspecified D22.9 Melanocytic nevi, unspecified L03.321 Acute lymphangitis of abdominal wall D23.0 Other benign neoplasm of skin of lip L03.322 Acute lymphangitis of back [any part except buttock] D23.10 Other benign neoplasm of skin of unspecified eyelid, including canthus L03.323 Acute lymphangitis of chest wall D23.111 Other benign neoplasm of skin of right upper eyelid, including canthus L03.324 Acute lymphangitis of groin D23.112 Other benign neoplasm of skin of right lower eyelid, including canthus L03.325 Acute lymphangitis of perineum D23.121 Other benign neoplasm of skin of left upper eyelid, including canthus L03.326 Acute lymphangitis of umbilicus D23.122 Other benign neoplasm of skin of left lower eyelid, including canthus L03.327 Acute lymphangitis of buttock D23.20 Other benign neoplasm of skin of unspecified ear and external auricular canal L03.329 Acute lymphangitis of trunk, unspecified

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D23.21 Other benign neoplasm of skin of right ear and external auricular canal L03.31A Cellulitis of flank D23.22 Other benign neoplasm of skin of left ear and external auricular canal L03.32A Acute lymphangitis of flank D23.30 Other benign neoplasm of skin of unspecified part of face L03.811 Cellulitis of head [any part, except face] D23.39 Other benign neoplasm of skin of other parts of face L03.818 Cellulitis of other sites D23.4 Other benign neoplasm of skin of scalp and neck L03.891 Acute lymphangitis of head [any part, except face] D23.5 Other benign neoplasm of skin of trunk L03.898 Acute lymphangitis of other sites D23.60 Other benign neoplasm of skin of unspecified upper limb, including shoulder L03.90 Cellulitis, unspecified D23.61 Other benign neoplasm of skin of right upper limb, including shoulder L03.91 Acute lymphangitis, unspecified D23.62 Other benign neoplasm of skin of left upper limb, including shoulder L08.0 Pyoderma D23.70 Other benign neoplasm of skin of unspecified lower limb, including hip L08.89 Other specified local infections of the skin and subcutaneous tissue D23.71 Other benign neoplasm of skin of right lower limb, including hip L08.9 Local infection of the skin and subcutaneous tissue, unspecified

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D23.72 Other benign neoplasm of skin of left lower limb, including hip L24.9 Irritant contact dermatitis, unspecified cause D23.9 Other benign neoplasm of skin, unspecified L24.A Irritant contact dermatitis due to friction or contact with body fluids D28.0 Benign neoplasm of vulva L29.81 Cholestatic pruritus D28.1 Benign neoplasm of vagina L29.89 Other pruritus D29.0 Benign neoplasm of penis L29.9 Pruritus, unspecified D29.20 Benign neoplasm of unspecified testis L30.8 Other specified dermatitis D29.21 Benign neoplasm of right testis L30.9 Dermatitis, unspecified D29.22 Benign neoplasm of left testis L50.8 Other urticaria D29.30 Benign neoplasm of unspecified epididymis L50.9 Urticaria, unspecified D29.31 Benign neoplasm of right epididymis L51.8 Other erythema multiforme D29.32 Benign neoplasm of left epididymis L51.9 Erythema multiforme, unspecified D29.4 Benign neoplasm of scrotum L53.8 Other specified erythematous conditions D36.7 Benign neoplasm of other specified sites L53.9 Erythematous condition, unspecified H00.11 Chalazion right upper eyelid M79.601 Pain in right arm

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H00.12 Chalazion right lower eyelid M79.602 Pain in left arm H00.14 Chalazion left upper eyelid M79.603 Pain in arm, unspecified H00.15 Chalazion left lower eyelid M79.604 Pain in right leg H02.61 Xanthelasma of right upper eyelid M79.605 Pain in left leg H02.62 Xanthelasma of right lower eyelid M79.606 Pain in leg, unspecified H02.64 Xanthelasma of left upper eyelid M79.609 Pain in unspecified limb H02.65 Xanthelasma of left lower eyelid M79.621 Pain in right upper arm H02.821 Cysts of right upper eyelid M79.622 Pain in left upper arm H02.822 Cysts of right lower eyelid M79.629 Pain in unspecified upper arm H02.824 Cysts of left upper eyelid M79.631 Pain in right forearm H02.825 Cysts of left lower eyelid M79.632 Pain in left forearm H61.011 Acute perichondritis of right external ear M79.639 Pain in unspecified forearm H61.012 Acute perichondritis of left external ear M79.641 Pain in right hand H61.013 Acute perichondritis of external ear, bilateral M79.642 Pain in left hand H61.021 Chronic perichondritis of right external ear M79.643 Pain in unspecified hand

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H61.022 Chronic perichondritis of left external ear M79.644 Pain in right finger(s) H61.023 Chronic perichondritis of external ear, bilateral M79.645 Pain in left finger(s) H61.031 Chondritis of right external ear M79.646 Pain in unspecified finger(s) H61.032 Chondritis of left external ear M79.651 Pain in right thigh H61.033 Chondritis of external ear, bilateral M79.652 Pain in left thigh I78.1 Nevus, non-neoplastic M79.659 Pain in unspecified thigh K13.21 Leukoplakia of oral mucosa, including tongue M79.661 Pain in right lower leg K13.3 Hairy leukoplakia M79.662 Pain in left lower leg K13.5 Oral submucous fibrosis M79.669 Pain in unspecified lower leg K62.82 Anal sphincter tear (healed) (nontraumatic) (old) M79.671 Pain in right foot K64.4 Residual hemorrhoidal skin tags M79.672 Pain in left foot L11.0 Acquired keratosis follicularis M79.673 Pain in unspecified foot L11.8 Other specified acantholytic disorders M79.674 Pain in right toe(s) L56.8 Other specified acute skin changes due to ultraviolet radiation M79.675 Pain in left toe(s)

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L57.8 Other skin changes due to chronic exposure to nonionizing radiation M79.676 Pain in unspecified toe(s) L57.9 Skin changes due to chronic exposure to nonionizing radiation, unspecified R20.8 Other disturbances of skin sensation L66.4 Folliculitis ulerythematosa reticulata R20.9 Unspecified Disturbances of Skin Sensation
L72.0 Epidermal cyst R21 Rash and other nonspecific skin eruption L72.11 Pilar cyst R22.0 Localized swelling, mass and lump, head L72.12 Trichodermal cyst R22.1 Localized swelling, mass and lump, neck L72.2 Steatocystoma multiplex R22.2 Localized swelling, mass and lump, trunk L72.3 Sebaceous cyst R22.30 Localized swelling, mass and lump, unspecified upper limb L72.8 Other follicular cysts of the skin and subcutaneous tissue R22.31 Localized swelling, mass and lump, right upper limb L82.0 Inflamed seborrheic keratosis R22.32 Localized swelling, mass and lump, left upper limb L82.1 Other seborrheic keratosis R22.33 Localized swelling, mass and lump, upper limb, bilateral

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L85.0 Acquired ichthyosis R22.40 Localized swelling, mass and lump, unspecified lower limb L85.1 Acquired keratosis [keratoderma] palmaris et plantaris R22.41 Localized swelling, mass and lump, right lower limb L85.2 Keratosis punctata (palmaris et plantaris) R22.42 Localized swelling, mass and lump, left lower limb L85.8 Other specified epidermal thickening R22.43 Localized swelling, mass and lump, lower limb, bilateral L87.0 Keratosis follicularis et parafollicularis in cutem penetrans R22.9 Localized swelling, mass and lump, unspecified L87.1 Reactive perforating collagenosis R23.4 Changes in skin texture L87.2 Elastosis perforans serpiginosa R23.8 Other skin changes L87.8 Other transepidermal elimination disorders R23.9 Unspecified skin changes L90.3 Atrophoderma of Pasini and Pierini R26.2 Difficulty in walking, not elsewhere classified L90.4 Acrodermatitis chronica atrophicans R52 Pain, unspecified L90.5 Scar conditions and fibrosis of skin R58 Hemorrhage, not elsewhere classified L90.8 Other atrophic disorders of skin R60.0 Localized edema L91.0 Hypertrophic scar R60.1 Generalized edema

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L91.8 Other hypertrophic disorders of the skin R60.9 Edema, unspecified L91.9 Hypertrophic disorder of the skin, unspecified

L92.2 Granuloma faciale [eosinophilic granuloma of skin]

L92.3 Foreign body granuloma of the skin and subcutaneous tissue L92.8 Other granulomatous disorders of the skin and subcutaneous tissue L98.0 Pyogenic granuloma L98.5 Mucinosis of the skin L98.6 Other infiltrative disorders of the skin and subcutaneous tissue L98.8 Other specified disorders of the skin and subcutaneous tissue L98.9 Disorder of the skin and subcutaneous tissue, unspecified L99 Other disorders of skin and subcutaneous tissue in diseases classified elsewhere N75.0 Cyst of Bartholin's gland N84.3 Polyp of vulva N90.0 Mild vulvar dysplasia

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N90.1 Moderate vulvar dysplasia Q18.1 Preauricular sinus and cyst Q82.1 Xeroderma pigmentosum Q82.3 Incontinentia pigmenti Q82.5 Congenital non-neoplastic nevus Q82.8 Other specified congenital malformations of skin Q85.01 Neurofibromatosis, type 1 Q85.03 Schwannomatosis Q85.09 Other neurofibromatosis

Description A skin lesion is a superficial growth or area of the skin that does not resemble the surrounding area of adjacent skin.

When the skin is exposed to the sun's ultraviolet radiation, lesions can develop on the skin. Skin lesions can also arise in other areas with minimal exposure to the sun. Some skin lesions are pre-malignant and can lead to skin cancer, e.g., actinic keratosis transforming into squamous cell carcinoma. Due to the risk of progression of these lesions to skin cancer, removal or treatment of the skin lesions can be done to diminish the risk of transformation.

The three most common types of skin cancer in the United States are:

1. Basal cell carcinoma, 2. squamous cell carcinoma, and 3. melanoma. All three can occur anywhere on the skin but are most prominent on sun-exposed areas.

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The ABCDEs of melanoma are some of the common, clinical characteristics used by dermatologists to classify melanomas, and are the most widely known among the lay public because of the excellent educational efforts made by the American Academy of Dermatology as well as practicing dermatologists and other health care professionals to educate patients. These features include (but are not limited to) the following:

• A is for Asymmetry: One half of the spot is unlike the other half. • B is for Border: The spot has an irregular, scalloped, or poorly defined border. • C is for Color: The spot has varying colors from one area to the next, such as shades of tan, brown or black, or areas of white, red, or blue. • D is for Diameter: While melanomas are usually greater than 6 millimeters, or about the size of a pencil eraser, when diagnosed, they can be smaller. • E is for Evolving: The spot looks different from the rest or is changing in size, shape, or color. American Academy of Dermatology

If a sample of a lesion is obtained to diagnose the lesion, and the lesion is not excised, a biopsy may be appropriate rather than an excision. If choosing to excise rather than perform a biopsy/partial sampling of a lesion, the provider documentation should specify the reason for choosing an excision, such as the functional status of the patient, suspicion for malignancy, where incomplete sampling of the lesion will increase the chance of misdiagnosis, or size or depth of the lesion makes it important to remove the entire lesion.

Removal of benign lesions not suspicious for cancer may be clinically appropriate when removal will: improve the member’s medical health, fix a functional impairment, reduce pain, recurrent bleeding, recurrent inflammation (clinical signs may include: edema, oozing, erythema or bleeding or history of these signs); pruritus, or recurrent physical trauma (e.g. acrochordons along the bra line that are frequently traumatized causing bleeding, an eyelid lesion that causes visual obstruction); or reduce the risk of infectious spread to patient or other people (e.g. warts, molluscum or condyloma).

Policy History Date Action 10/2025 Clarified coding information.
1/2024 Annual policy review. Policy criteria reformatted. Policy intent and criteria unchanged. Diagnoses codes list added. New diagnoses-to-CPT codes edit implemented. Effective January 1, 2024.
1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
6/2020 Policy criteria unchanged. Effective 6/1/2020. 3/2015 New benign lesions criteria added; policy transferred from medical policy #068, Plastic Surgery. Effective 3/1/2015.
11/2014 Reviewed Medical Policy Group - Plastic Surgery and Dermatology, no change in coverage. 11/2013 Reviewed Medical Policy Group - Plastic Surgery and Dermatology, no change in coverage. 11/2012 Reviewed Medical Policy Group - Plastic Surgery and Dermatology, no change in coverage. 11/2011 Reviewed Medical Policy Group - Plastic Surgery and Dermatology, no change in coverage. 11/2010 Reviewed Medical Policy Group - Plastic Surgery and Dermatology, no change in coverage. 5/1998 Included coverage for benign lesions when medically necessary, i.e., bleeding, pain, recent change in color or enlargement, exposed to frequent irritation. Effective October 1, 1998.

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Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Alerić Z, Bauer V. Skin growths of the head and neck region in elderly patients--analysis of two five- year periods in General Hospital Karlovac, Croatia. Coll Antropol. 2011; 35 Suppl 2:195-198.
2. Feldman SR, Fleischer AB Jr. Progression of actinic keratosis to squamous cell carcinoma revisited: clinical and treatment implications. Cutis. 201; 87(4):201-207.
3. Lanssens S, Ongenae K. Dermatologic lesions and risk for cancer. Acta Clin Belg. 2011; 66(3):177-
5. Rigel DS, Stein Gold LF. The importance of early diagnosis and treatment of actinic keratosis. J Am Acad Dermatol. 2013; 68(1 Suppl 1):S20-27.
6. Tannous ZS, Mihm MC Jr, Sober AJ, Duncan LM. Congenital melanocytic nevi: clinical and histopathologic features, risk of melanoma, and clinical management. J Am Acad Dermatol. 2005;52(2):197-203.

7. Beers MH, Jones TV, Berkwitz M, et al., eds. Skin cancers: Premalignant lesions. In: The Merck Manual of Geriatrics. 3rd ed. Sec. 15, Ch. 125. White House Station, NJ: Merck & Co.; 2000.

   Endnotes

   1 Based on expert opinion