303 Form

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

Policy Number: 303

BCBSA Reference Number: 2.01.59A (For Plan internal use only) NCD/LCD: NA Related Policies
Dermatoscopy, #519

Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Ultrasonographic evaluation of skin lesions is INVESTIGATIONAL.

Ultrasonographic evaluation as a technique to assess photo-aging or skin rejuvenation techniques is considered cosmetic in nature, and therefore is 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) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s

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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.

CPT Codes There is no specific CPT code for this service.

Description Ultrasonographic evaluation of skin lesions refers to the use of ultrasound to determine the margins and depth of surface tumors or inflammatory skin conditions. Ultrasound transducers of at least 20 MHz are used. The following applications of ultrasonographic evaluation have been proposed: • To assess the margins and depth of melanoma and non-melanoma skin cancers to aid in surgical planning, • To assess actinic keratoses to determine if cryosurgery is an appropriate therapeutic option, • To follow the course of connective diseases of the skin (i.e., scleroderma) by evaluating the amount and location of collagen in the dermis, and • To assess inflammatory skin diseases, such as allergic reactions or psoriasis.

Examples of ultrasonographic evaluations of skin lesions include the Episcan® I-200 Ultrasound System from Longport, Inc. and the DermaScan™ C Ultrasonic System from Cortex Technology. All ultrasonographic evaluations of skin lesions are considered investigational or not medically necessary regardless of the commercial name, the manufacturer or FDA approval status.

Summary The evidence is insufficient for determining whether the use of ultrasound leads to improved health outcomes in patients with skin lesions. No identified study examined whether the use of ultrasonography preoperatively resulted in improved health outcomes, such as lower rates of disease recurrence or increased survival. Given the lack of sufficient high-quality evidence on the impact of ultrasound skin imaging on patient management, this technology is considered investigational. In addition, due to the cosmetic nature of the application, ultrasound skin imaging is considered not medically necessary to assess photoaging or skin rejuvenation techniques.

Policy History Date Action 11/2022 Annual policy review. Policy updated with literature review through October 2022. No references added. Policy statements unchanged. 2/2020 Policy updated with literature review through February 1, 2020, no references added. Policy statements unchanged. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
1/12/2011 New policy, effective 1/12/2011 describing ongoing non-coverage.
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

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References

1. Desai TD, Desai AD, Horowitz DC et al. The use of high-frequency ultrasound in the evaluation of superficial and nodular basal cell carcinomas. Dermatol Surg 2007; 33(10):1220-7.
2. Bessoud B, Lassau N, Koscielny S et al. High frequency sonography and color Doppler in the management of pigmented skin lesions. Ultrasound Med Biol 2003; 29(6):875-79.
3. Bobadilla F, Wortsman X, Munoz C et al. Pre-surgical high resolution of facial basal cell carcinoma: correlation with histology. Cancer Imaging 2008; 8:163-72.
4. El-Zawahry MB, Abdel El-Hameed El-Cheweikh HM, Abd-El-Rahman Ramadan S et al. Ultrasound biomicroscopy in the diagnosis of skin diseases. Eur J Dermatol 2007; 17(6):469-75.
5. Semple JL, Gupta AK, From L et al. Does high-frequency (40-60MHz) ultrasound imaging play a role in the clinical management of cutaneous melanoma? Ann Plast Surg 1995; 34(6):599-606.
6. Partsch B, Binder M, Puspok-Schwarz M et al. Limitations of high frequency ultrasound in determining the invasiveness of cutaneous malignant melanoma. Melanoma Res 1996; 6(5):395-8.
7. Machet L, Belot V, Naouri M et al. Preoperative measurement of thickness of cutaneous melanoma using high-resolution 20 MHZ ultrasound imaging: a monocenter prospective study and systematic review of the literature. Ultrasound Med Biol; 2009; 35(9):1411-20.
8. Gambichler T, Moussa G, Bahrenberg K et al. Preoperative ultrasonic assessment of thin melanocytic skin lesions using a 100-MHz ultrasound transducer: a comparative study. Dermatol Surg 2007; 33(7):818-24.
9. Music MM, Hertl K, Kadivec M et al. Pre-operative ultrasound with a 12-15 MHz linear probe reliably differentiates between melanoma thicker and thinner than 1mm. J Eur Acad Dermatol Venereol 2010; 24(9):1105-8.
10. Kaikaris V, Samsanavicius D, Maslauskas K et al. Measurement of melanoma thickness- comparison of two methods: ultrasound versus morphology. J Plast Reconstr Aesthet Surg 2011; 64(6): 796-802.
11. Jambusaria-Pahlajani A, Schmults CD, Miller CJ et al. Test characteristics of high-resolution ultrasound in the preoperative assessment of margins of basal cell and squamous cell carcinoma in patients undergoing Mohs micrographic surgery. Dermatol Surg 2009; 35(1):9-15.
12. Wortsman X, Wortsman J. Clinical usefulness of variable-frequency ultrasound in localized lesions of the skin. J Am Acad Dermatol 2010; 62(2): 247-56.
13. National Comprehensive Cancer Network. Melanoma. Clinical practice guidelines in oncology, v1.2012. Available online at: http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf . Last accessed August 2011
14. Suliman YA, et al. Ultrasound characterization of cutaneous ulcers in systemic sclerosis. Clin Rheumatol 2018 - Clinical Trial. PMID 29525847