LCD L33436

Coverage Guidance

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis and/or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(10) where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §120 Cosmetic Surgery

Indications and Limitations of Coverage

Medicare will consider reimbursement for Mohs micrographic surgery (MMS) for accepted diagnoses and indications. Current accepted diagnoses and indications are listed in this LCD. The physician performing the MMS must be trained and highly skilled in MMS techniques, and pathology identification. The physician must document in the patient's medical record that the diagnosis is appropriate for MMS and that MMS is the most appropriate choice as the treatment of the particular lesion.

Medicare is aware that a biopsy of the skin lesion for which Mohs surgery is planned is necessary in order for the physician to determine the exact nature of the lesion(s) to be removed. Occasionally, that biopsy may need to be done on the same day that the Mohs surgery is planned to be done.

No payment will be allowed for the biopsy and pathology of a lesion, which requires removal by the MMS technique, if a biopsy of that lesion has been performed within 60 days prior to MMS. An exception exists when a biopsy has been performed within that period and the biopsy results could not be obtained by the Mohs surgeon using reasonable effort. The clinical record must clearly show that this situation existed.

Current accepted diagnoses and indications for MMS are:

Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas in anatomic locations where they are prone to recur:

• Central facial areas, nose and temple areas of the face (the so-called "mask area" of the face), which includes the eyebrows and periorbital areas, the superolateral temple areas, and the preauricular and postauricular areas.

• Lips, cutaneous and vermilion.

• Eyelids.

• The entire external ear and ear canal.

Other skin lesions:

• Angiosarcoma of the skin.

• Keratoacanthoma, recurrent or rapidly growing destructive variants.

• Dermatofibrosarcoma protuberans.

• Malignant fibrous histiocytoma.

• Sebaceous gland carcinoma.

• Microcystic adnexal carcinoma.

• Extramammary Paget's disease.

• Bowenoid papulosis.

• Merkel cell carcinoma.

• Bowen's disease (squamous cell carcinoma in situ).

• Adenoid type of squamous cell carcinoma.

• Rapid growth in a squamous cell carcinoma.

• Longstanding duration of a squamous cell carcinoma.

• Verrucous carcinoma.

• Atypical fibroxanthoma.

• Leiomyosarcoma or other spindle cell neoplasms of the skin.

• Adenoid Cystic carcinoma of the skin.

• Erythroplasia of Queyrat.

• Oral and central facial, and paranasal sinus neoplasm.

• Apocrine carcinoma of the skin.

• Malignant melanoma or melanoma in situ (facial, auricular, genital and digital) when anatomical or technical difficulties do not allow conventional excision with appropriate margins.

• Rare, biopsy-proven skin malignancies not otherwise addressed in this section.

• Basal cell carcinomas, squamous cell carcinomas or basalosquamous cell carcinomas having one or more of the following features:

• Are recurrent.

• Biopsy proven lesions with aggressive pathology as documented by at least 1 of the following microscopic characteristics:

• Sclerotic.

• Fibrosing.

• Morphea-like.

• Metatypical/infiltrative/spikey shaped cell groups.

• Perineural or perivascular invasion.

• Nuclear pleomorphism.

• High mitotic activity or superficial multicentric.

• Located in the following areas: genitalia, digits or nail unit/periungual.

• Large size (1.0 cm or greater in the non-mask areas of the face and 2.0 cm or greater in other areas).

• Positive margins on recent excision.

• Poorly defined borders.

• Present in the very young (less than 40 years of age).

• Radiation-induced.

• In patients with proven difficulty with skin cancers or who are immunocompromised.

• Basal cell nevus syndrome.

• Present in an old scar (e.g., Marjolin's ulcer).

• Associated with xeroderma pigmentosum or difficulty estimating depth of lesion.

• Laryngeal carcinoma in certain limited clinical situations.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

The physician must document in the patient's medical record that the diagnosis is appropriate for MMS and that MMS is the most appropriate choice as the treatment of the particular lesion.

The surgeon's documentation in the patient's medical record should be legible and support the medical necessity of this procedure. Operative notes and pathology documentation in the patient's medical record should clearly show MMS was performed using accepted Mohs technique, in which the physician acts in 2 integrated and distinct capacities: surgeon and pathologist (e.g., should show that true Mohs surgery was performed).

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to the A/B MAC upon request.

Bibliography

• Bichakjian CK, Halpern AC, Johnson TM, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2011;65(5):1032-1047.

• Clark D. Cutaneous micrographic surgery. Otolaryngol Clin North Amer. 1993;26(2):185-202.

• Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for malignant melanoma. J Am Acad Dermatol. 1993;28(4):638-641.

• Drake LA, Dinehart SM, Goltz RW, et al. Guidelines of care for Mohs micrographic surgery. J Am Acad Dermatol. 1995;33(2)(Pt 1):271-278.

• Dzubow LM. Mohs surgery. Lancet. 1994;343(8895):433-434.

• Finley EM. The principles of Mohs micrographic surgery for cutaneous neoplasia. The Ochsner Journal. 2003;5(2):22-33.

• McGillis ST, Wheeland RG, Sebben JE. Current issues in the performance of Mohs micrographic surgery. J Dermatol Surg Oncol. 1991;17(8):681-684.