LCD L33818

Coverage Guidance

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Excision of Malignant Skin Lesions. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Excision of Malignant Skin Lesions and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

• CMS IOM Publication 100-08, Medicare Program Integrity Manual,

• Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Indications and Limitations of Coverage

History/Background and/or General Information

A skin lesion is any alteration in the normal skin architecture. Lesions can be benign, pre-malignant or malignant. The most common malignant lesions are Basal Cell Carcinomas (BCC), Squamous Cell Carcinomas (SCC) and Melanomas.

Four of the most common methods of treatment of malignant skin lesions are:

• Surgical excision,

• Electrodesiccation (tissue destruction by heat),

• Radiation therapy, or

• Cryosurgery (tissue destruction by freezing)

Covered Indications

The treatment of choice for malignant skin lesions is complete excision that includes a variable margin of surrounding tissue in order to eradicate microscopic tumor cells, which may have spread beyond the visible borders of the lesion.

The excision of a malignant skin lesion including margins will be considered medically necessary when a pathology report verifies the existence of a malignancy.

Limitations

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

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Analysis of Evidence

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Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Excision of Malignant Skin Lesions (A57660) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Excision of Malignant Skin Lesions (A57660) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Bibliography

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