Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 09|01|2019 POLICY LAST UPDATED: 04|06|2022

OVERVIEW This policy documents that coverage is only provided for removal of symptomatic lesions.

PRIOR AUTHORIZATION Not applicable

POLICY STATEMENT Medicare Advantage Plans Removal of benign skin lesions, including skin tags, are covered when signs or symptoms which warrant medical intervention are present.

If the procedure is cosmetic in nature, the claim should be filed with the following diagnosis Z41.1. This will ensure that the claim will deny as not covered.

The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be a part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.

Commercial Products Symptomatic benign skin lesions including subcutaneous tissue, lesion removal/treatment is a covered service. If the procedure is cosmetic in nature, the claim should be filed with the following diagnosis Z41.1.

Skin tag removal is considered to be cosmetic and is not covered.

The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be a part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.

MEDICAL CRITERIA None

BACKGROUND Benign skin lesions are common and are frequently removed at the patient’s request to improve appearance. Removal of certain asymptomatic benign skin lesions that do not pose a threat to health or function are considered cosmetic and as such are not covered and considered contract exclusions.

Benign skin lesions include, but are not limited to, seborrheic keratosis and sebaceous (epidermoid) cysts. Other skin lesions include, but are not limited to, viral infectious lesions, i.e., condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (e.g., common, plantar, flat), milia, or other benign, premalignant (e.g., actinic keratosis), or malignant lesions.

Payment Policy |Benign Skin Lesions and Viral Infectious Lesion Removal

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Skin lesion removal/treatment can be accomplished using various methods-excision, paring, curettage, ablative destruction and shaving:
• Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed.
• Paring involves cutting off the outer coating, layer, or part of a lesion.
• Curettage is a surgical scraping or cleaning by means of a curette. • Destruction involves the ablation of benign, premalignant or malignant tissues by any method; electrosurgery, cryosurgery, laser and chemical treatment, with or without curettage, including local anesthesia, and not usually requiring closure. • Shaving involves taking a thin slice off the top of the skin. It is also used to remove superficial abnormal areas.

There may be instances when the removal of skin lesions is not cosmetic. Removal of these non-cosmetic skin lesions is typically performed when the following conditions are present and clearly documented in the member’s medical record: • The lesion has one or more of the following characteristics: bleeding; intense itching or pain, sudden enlargement (over a 1-month observation). • The lesion has physical evidence of inflammation, (e.g., purulence, ulceration, oozing, edema or erythema etc.). • The lesion obstructs an orifice or restricts vision. • There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic condition based on lesion appearance. • A prior biopsy suggests or is indicative of lesion malignancy. • The lesion is an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has, in fact, occurred.

In addition, wart destruction is typically performed when the following clinical circumstances are present: • Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding. • Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients. • Other infections (e.g., molluscum) or any other condition in which wart removal is not cosmetic.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable surgery or non-covered benefits/coverage.

CODING Medicare Advantage Plans and Commercial Products If the procedure is cosmetic in nature, the claim should be filed with the following diagnosis Z41.1. This will ensure that the claim will deny as not covered.

Commercial Products The following skin tag removal codes are considered cosmetic and not covered: 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

RELATED POLICIES Cosmetic Services/Procedures

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

PUBLISHED Provider Update, June 2022 Provider Update, April 2021 Provider Update, May 2020 Provider Update, November 2019 Provider Update, June 2018

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS