Point32 Mohs’ Micrographic Surgery Form

Mohs' Micrographic Surgery

Mohs’ Micrographic Surgery is a specialized surgical technique for the thorough removal of complex and ill-defined skin cancers. The known tumor is excised with a narrow margin and immediately examined under a microscope to assess if and where it extends beyond the excision. Those extensions are themselves excised and examined in an iterative process ending when no signs of cancer are visible in examination of the cut surface.

Clinical Guideline Coverage Criteria

The Plan considers Mohs surgery as reasonable and medically necessary when performed by an ACMS-certified physician (e.g., dermatologist, plastic surgeon) who is trained in MMS techniques and pathological identification and documentation confirms ONE of the following:

1. Basal cell carcinoma (BCC) in ONE of the following locations:
   • Mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola when
     • BCC is recurrent or
     • BCC has unexpected positive margin on a recent excision or
     • BCC is primary aggressive, nodular, or superficial or
     • BCC has no identified sub-type or is sub-type adenoid, cystic, adamantoid, or fibroepithelioma of Pinkus or
     • BCC is on the face or
     • Member has a genetic syndrome imparting a predisposition to skin cancer
   • Cheeks, forehead, scalp, neck, jawline, pretibial surface when
     • BCC is recurrent or
     • BCC has unexpected positive margin on a recent excision or
     • BCC is primary aggressive or nodular or
     • BCC has no identified sub-type or is sub-type adenoid, cystic, adamantoid, or fibroepithelioma of Pinkus or
     • BCC is on the face and either
       • Tumor is larger than 1 cm or
       • BCC has aggressive histology
     • BCC is primary superficial and either
       • Member is immunocompromised or
       • Tumor is larger than .5cm
     • Member has a genetic syndrome imparting a predisposition to skin cancer
   • Trunk and extremities (excluding pretibial surfaces, hands, feet, and ankles) when
     • BCC is recurrent and aggressive or nodular
     • BCC has unexpected positive margin on a recent excision and is aggressive or nodular
     • BCC is primary aggressive and larger than .5cm
     • BCC has no identified sub-type or is sub-type adenoid, cystic, adamantoid, or fibroepithelioma of Pinkus and is larger than 2cm or
     • BCC is nodular and either
       • Member is immunocompromised or
       • Tumor is larger than 2cm or
     • Member has a genetic syndrome imparting a predisposition to skin cancer
   • Previously (non-solar) irradiated skin
   • Traumatic scars
   • Osteomyelitic regions
   • Chronically inflamed/ulcerated regions
2. Squamous cell carcinoma (SCC) in ONE of the following locations:
   • Mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola when
     • SCC is recurrent or
     • SCC has an unexpected positive margin on a recent excision or
     • SCC is primary aggressive, verrucous, or KA type or
     • SCC does not have aggressive histologic features or a Clark level greater than III or
     • SCC is Bowen disease/in situ or
     • Member has a genetic syndrome imparting a predisposition to skin cancer
   • Cheeks, forehead, scalp, neck, jawline, pretibial surface when
     • SCC is recurrent or has an unexpected positive margin on a recent excision and is
       • Aggressive,
       • KA type,
       • In situ/Bowen, or
       • Is less than two millimeters in depth and has a Clark level no greater than III with no aggressive histologic features
     • SCC is primary aggressive or KA type, or
     • SCC does not have aggressive histologic features or a Clark level greater than III, or

• SCC is primary Bowen disease/in situ, or
• Member has a genetic syndrome imparting a predisposition to skin cancer

c. Trunk and extremities (excluding pretibial surfaces, hands, feet, and ankles) when

1. SCC is recurrent or has an unexpected positive margin on a recent excision and is
   • Aggressive,
   • KA type, or
   • is less than two millimeters in depth and has a Clark level no greater than III with no aggressive histologic features, or
2. SCC is primary aggressive, or
3. SCC is KA type and is either
   • Larger than half a centimeter in an immunocompromised member or
   • Larger than a centimeter in a member with a healthy immune system or
4. SCC does not have aggressive histologic features or a Clark level greater than III and is either
   • Larger than a centimeter in an immunocompromised member or
   • Larger than two centimeters in a member with a healthy immune system or
5. SCC is Bowen disease/in situ and is either
   • Larger than a centimeter in an immunocompromised member or
   • Larger than two centimeters in a member with a healthy immune system or
6. Member has a genetic syndrome imparting a predisposition to skin cancer

Point32Health companies Mohs Micrographic Surgery (MMS)

d. Previously (non-solar) irradiated skin

e. Traumatic scars

f. Osteomyelitic regions

g. Chronically inflamed/ulcerated region

3. Lentigo maligna in ONE of the following locations:

• Mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola, cheeks, forehead, scalp, neck, jawline, pretibial surface
• Trunk and extremities (excluding pretibial surfaces, hands, feet, and ankles) WHEN lentigo maligna is locally recurrent

4. Melanoma in situ in ONE of the following locations:

• Mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola, cheeks, forehead, scalp, neck, jawline, pretibial surface
• Trunk and extremities (excluding pretibial surfaces, hands, feet, and ankles) WHEN melanoma in situ is locally recurrent

5. Adenocystic carcinoma
6. Adnexal carcinoma
7. Angiosarcoma
8. Apocrine/eccrine carcinoma
9. Atypical Fibroxanthoma
10. Dermatofibrosarcoma protuberans
11. Desmoplastic trichoepithelioma in the mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola, cheeks, forehead, scalp, neck, jawline, or pretibial surface
12. Extramammary Paget's Disease
13. Leiomyosarcoma
14. Malignant fibrous histiocytoma
15. Undifferentiated pleomorphic sarcoma
16. Merkel cell carcinoma in the mask areas of the 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 areas, excluding scrotum), hands, feet, nail units, ankles, nipples/areola, cheeks, forehead, scalp, neck, jawline, or pretibial surface
17. Microcystic adnexal carcinoma
18. Mucinous carcinoma
19. Rare biopsy proven skin cancers (not otherwise specified)
20. Sebaceous carcinoma

Note: Mohs requires the integration of an individual functioning in two separate and distinct capacities as the surgeon and pathologist.

The operative note and pathology documentation in the patient’s medical record must clearly show the Mohs service was performed using accepted Mohs technique, with the physician performing both the surgical and pathology Point32Health companies Mohs Micrographic Surgery (MMS) 3 services.

Guidelines:

Clark’s level is a system of skin cancer staging, classifying melanomas by invasion extent.

• Melanoma confined to the epidermis (melanoma in situ)
• Invasion into the papillary dermis
• Invasion to the junction of the papillary and reticular dermis
• IV Invasion into the reticular dermis

Limitations

The Plan considers Mohs micrographic surgery (MMS) as experimental/investigational for all other indications and locations. In addition, the plan does not cover MMS for the treatment of:

1. Actinic keratosis (AK) with focal SCC in situ, Bowenoid AK, or AK-type SCC in situ
2. Bowenoid papulosis
3. Internal cancers, such as invasive laryngeal carcinoma, intraoral, pharyngeal, sinus, and esophageal carcinomas

Codes