CMS Removal of Benign Skin Lesions Form

Summary Of Evidence

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Analysis of Evidence

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Notice: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Benign lesions may be removed in a variety of ways. These methods can be grouped into one of the following three categories.

1. Shaving of Epidermal or Dermal Lesions
   • Shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision. This includes local anesthesia, chemical or electrocauterization. The wound does not require suture closure.
2. Excision - Benign Lesions
   • Excision of benign lesions of skin includes local anesthesia. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed.
3. Destruction, Benign Lesions
   • Destruction means the ablation of benign tissues by any method, with or without curettement, including local anesthesia, and not usually requiring closure.
   • Medical record documentation must support medical necessity for excisional removal of a benign skin lesion for other than cosmetic purposes. Each benign lesion excised should be reported separately.

Covered Indications

In selected circumstances, the removal of lesions (e.g., seborrheic keratoses, epidermoid cysts, moles [nevi], acquired hyperkeratosis, molluscum contagiosum, milia, viral warts, benign neoplasms, hemangiomas, lipomas, and pyogenic granulomas) is medically appropriate. Therefore, Medicare will consider their removal as medically necessary, and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record:

1. The lesion has become symptomatic or has undergone a change in appearance or displays evidence of inflammation or infection.
2. The lesion obstructs an orifice.
3. The lesion clinically restricts eye function. For example, the lesion
   
   • restricts eyelid function
   • causes misdirection of eyelashes or eyelid
   • restricts lacrimal puncta and interferes with tear flow
   • touches the globe
   • interferes with vision
4. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance or prior biopsy of a related or similar lesion suggesting malignancy.
5. A prior histological exam or biopsy suggests or is indicative of atypia (e.g., atypical nevus) or malignancy.
6. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has occurred.
7. Removal of molluscum contagiosum.
8. Benign epidermal or pilar cyst with history of infection, drainage, or rupture.
9. Wart removals will be covered under guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are present:
   
   • Periocular warts associated with chronic recurrent conjunctivitis thought to be secondary to lesion virus shedding
   • Warts showing evidence of spread from one body area to another
   • Lesions are condyloma acuminate
10. Please refer to the National Coverage Determination (NCD) 250.4 for coverage details regarding Actinic Keratosis.

Limitations

The following are considered not reasonable and necessary and therefore will be denied:

1. Please refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.6 for instructions regarding Evaluation and Management (E/M) services during the global period of surgery and on the same day as a procedure.
2. Removal of certain benign skin lesions that do not pose a threat to health or function is considered cosmetic, and as such, is not covered by the Medicare program. If the beneficiary wishes to have one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The provider has the responsibility to notify the patient in advance that Medicare will not cover that cosmetic procedure and the beneficiary will be liable for the cost of the service.
3. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.