Health First MOHS Micrographic Surgery Form

HealthFirst Health Plans Medical Policy

Subject: MOHS Micrographic Surgery
Policy Number: MP - 0111

Applies To: Commercial only
Effective Date: May 19, 2010

Medicare will follow LCD 33689 Revision 3 (1/8/19) First Coast Service Options Inc (FL)

Number of Pages: 8

Medical Policy:

MOHs Micrographic Surgery may be considered medically necessary for skin lesions as identified in coverage covered indications below.

Definitions:

Mohs Micrographic Surgery – (MMS) Mohs micrographic surgery (MMS) is a microscope-guided tissue-sparing surgical procedure originally designed to minimize facial scaring. It is used for the removal of certain complex or ill-defined cutaneous neoplasms of the skin and histologic examination of 100% of the surgical margins. MMS uses precise measurements of tumor margins to remove cancerous cells and leave healthy tissue intact. The procedure is performed in successive stages to remove extensive tumors, as needed. The surgery requires the integration of an individual functioning in two separate and distinct capacities; a surgeon and a pathologist.

Area H (high risk) = “Mask areas” of face (central face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermillion], chin, ear and periauricular skin/sulci, temple), genitalia (including perineal and perianal), hands, feet, nail units, ankles, and nipples/areola

Area M (medium risk) = Cheeks, forehead, scalp, neck, jawline, pretibial surface

Area L (low risk) = Trunk and extremities, excluding pretibial surface, hands, feet, nail units, and ankles

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HealthFirst Health Plans Clinical Criteria:

The requesting specialist shall be a dermatologist or a plastic surgeon.

II. Covered Indications:

The appropriate use criteria recommendations (supported by AAD/ACMS/ASDSA/ASMS) provide a necessary starting point for consideration of Mohs micrographic surgical treatment of lesion(s). However, Mohs Micrographic Surgery is indicated only when the superficial (lateral) or deep margins of the cancer lesion are uncertain clinically AND the likelihood of surgical cure and reconstruction would be compromised without use of immediate microscopic examination of the surgical margins. Though complexity of the lesion (poorly defined borders, suspected deep invasion, recurrent lesion, prior radiation), lesion size/location, and maximum conservation of healthy tissue are to be addressed in the preoperative medical record, the surgeon must address why the lesion will not be managed by excision or destruction technique.

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III. Documentation Required:

1. Pre-procedure E/M note and post-procedure operative notes must address why the lesion will not be managed by standard excision or destruction technique.
2. When utilized or referred to a plastic surgeon, procedures for complex repair, adjacent tissue transfer or rearrangement, flap, or graft codes are employed must be explained.
3. Options for care (both the primary procedure options and repair options) must be discussed with the patient and clearly noted in the pre-procedure (or post procedure as appropriate) documentation.

IV. MOHS Surgery Medically Necessary Indications:

1. Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), basalosquamous/basosquamous cell carcinomas in anatomic locations H and M.
   • Area H: Mask areas of face and other listed regions.
   • Area M: Cheeks, forehead, scalp, neck, jawline, pretibial surface.
2. Basal cell carcinomas (BCC), squamous cell carcinomas (SCC), or basalosquamous/basosquamous cell carcinomas in anatomic locations H, M, and L arising in:o Prior radiated skino Traumatic scaro Area of osteomyelitiso Area of chronic inflammation/ulcerationo Patients with genetic syndromes
3. Certain recurrent skin cancers:
   • Recurrent aggressive BCC, SCC, or unexpected positive margin on recent excision.
   • In situ/Bowen SCC of any size or unexpected positive margin on recent excision.
4. Lentigo maligna, melanoma in situ, non-lentigo maligna - primary or locally recurrent when clinical staging and surgical treatment consistent with NCCN guidelines.
5. Less common skin cancers:
   • List including Adenocystic carcinoma, Atypical Fibroxanthoma, Merkel cell carcinoma, Sebaceous carcinoma, etc.
6. Additional general indications for all lesions listed above such as high risk recurrent skin cancers, aggressive histologic features, or chronic scar.

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Limitations

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HealthFirst Health Plans

Procedures that exceed the medical need will not be deemed reasonable and necessary, unless documentation in the form of pre-procedure E/M note and/or post-procedure operative notes address items listed in section III above.

The limitations listed in sections below refer to specific body areas and lesion characteristics. The use of Mohs Micrographic Surgery in these areas and for these conditions is not considered medically reasonable and necessary:

1. Both recurrent and primary actinic keratosis (AK) with focal SCC in situ; Bowenoid AK; SCC in situ (AK type) of any size in all areas in healthy or immunocompromised
2. Basal cell carcinoma located in Area L— trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles):
   • Recurrent superficial BCC (healthy or immunocompromised patients, or patients with genetic syndromes) of any size
   • Primary superficial BCC (healthy or immunocompromised patients) of any size
   • Primary nodular BCC (healthy patients) ≤ 2 cm
   • Primary nodular BCC (immunocompromised patients) ≤ 1 cm
3. Squamous cell carcinoma located in Area L— trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles):
   • Primary SCC; without aggressive histologic features, <2 mm depth without other defining features, Clark level ≤ III (healthy patients) ≤2 cm
   • Primary SCC keratoacanthoma (KA) type; not central facial (healthy patients) ≤ 1 cm
   • Primary in situ SCC/Bowen disease (healthy patients) ≤ 2 cm
   • Primary in situ SCC/Bowen disease (immunocompromised patients)≤ 1 cm
4. Desmoplastic trichoepithelioma located in Area L— trunk and extremities (excluding pretibial surface, hands, feet, nail units, and ankles)
5. Bowenoid papulosis
6. Mohs surgery is not covered unless the physician is:
   • A Licensed physician who has completed Residency training in Dermatology or General/subspeciality surgery
   • AND has completed additional medical training in Mohs surgery

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HealthFirst Health Plans

This additional training and expertise must be verifiable. Verification of this training should be available if requested during a pre or post payment medical review. Examples of verification are letter/certificate confirming fellowship program (program certified by a nationally recognized organization); residency program with letter confirming adequate MMS training (program certified by a nationally recognized organization); credible post-graduate training course/program covering Mohs micrographic surgery technique and pathology identification; credible preceptorship with demonstrated case experience and expertise. While Mohs surgery is a technical method of tissue handling and processing, the training and expertise of the surgeon greatly impacts the clinical outcome. The surgeon must act as the pathologist for all tissue sections (reliably read the frozen section pathology) and often must function as the reconstructive surgeon.

The qualified physician must provide services in the appropriate setting for the patient's medical need and condition. Success requires good tissue handling, good surgical technique, and standard of care tissue processing and staining technique. The Mohs surgery facility must meet standards of care as most are not affiliated with hospital delivery systems. A typical facility consists of procedure rooms suitable for dermatological surgery located in close proximity to a fully-equipped Mohs laboratory. The necessary equipment for Mohs cases of all complexities is available per standards of care. The Mohs laboratory typically has standard of care equipment such as cryostats, staining facilities (manual and/or automated) for standard staining of Mohs sections. There is access to appropriate immunohistochemical staining for selected Mohs cases. The setting must include a Mohs histolaboratory technician who will be either dedicated or one of a small team of biomedical staff who regularly cut Mohs sections and do sufficient numbers per week to maintain a high technical expertise in preparing Mohs sections.

NOTE: Health First does not pay for the services of Physician Assistants, Nurse Practitioners and other clinicians who do not meet the criteria set forth above in a-d above for MOHS procedures.

Medicare LCD: L33689 Revision 3 (1/8/19) First Coast Service Options Inc (FL)

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HealthFirst Health Plans

• Code: 17311
  Description: Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks
• Code: 17312
  Description: Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)
• Code: 17313
  Description: Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks
• Code: 17314
  Description: Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)
• Code: 17315
  Description: Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks