Skin lesions are areas of skin that differ from the skin around them. They may occur as a result of an injury or damage to the skin and are often noncancerous (benign) but may also be a sign of underlying conditions such as infections or autoimmune diseases. Symptoms of skin lesions may include abnormal growth, itchiness, swelling, pain, or change in color.

Clinical Guideline Coverage Criteria

1. The Plan considers the biopsy or removal of lesion suspicious for cancer as medically necessary when documentation confirms the following:
   • ABCDEs (asymmetry, border, color, diameter, evolution)
   • Dysplastic or atypical growth patterns
   • Prior biopsy demonstrating atypia, dysplasia suggesting malignancy
   • Other signs concerning for melanoma
2. The Plan considers the removal of non-pigmented lesion as medically necessary when documentation confirms thePoint32Health companies6744694 Removal of Benign Skin Lesions1 following:
   • Appearance is consistent with a non-melanoma skin cancer
3. The Plan considers the removal of benign lesions not suspicious of cancer as medically necessary when documentation confirms the following:
   • Lesion is causing a physical impairment (e.g., interferes with movement)
   • Lesion is causing significant symptoms (e.g., intense pain, burning, itching) that cannot be effectively treated with appropriate local and or systemic medications (e.g., analgesics, corticosteroids, antibiotics)
   • Lesion has a history of intermittent and recurrent breakdown that has been refractory to physiciansupervised local treatment

Limitations

The Plan considers biopsy or removal of skin lesions as not medically necessary for appearance or personal preference.

Codes