LCD L34200

Coverage Guidance

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Indications and Limitations of Coverage

Abstract:

Benign skin lesions are common in the elderly and are frequently removed at the patient's request to improve appearance. Removals of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic, and as such, are not covered by the Medicare program. These cosmetic reasons include, but are not limited to, emotional distress, "makeup trapping," and non-problematic lesions in any anatomic location. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone.

Benign skin lesions to which the accompanying lesion removal policy applies are the following: seborrheic keratoses, sebaceous (epidermoid) cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts.

Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient characteristics.

Indications:

There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts is medically appropriate. Medicare will, therefore, consider their removal as medically necessary, and not cosmetic, if one or more of the following conditions are presented and clearly documented in the medical record:

• Bleeding;

• Intense itching;

• Pain;

• Change in physical appearance (reddening or pigmentary change);

• Recent enlargement;

• Increase in the number of lesions;

• Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.;

• Lesion obstructs an orifice;

• Lesion clinically restricts eye function. For example:

• Lesion restricts eyelid function;

• lesion causes misdirection of eyelashes or eyelid;

• lesion restricts lacrimal puncta and interferes with tear flow;

• lesion touches globe;

• Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance;

• A prior biopsy suggests or is indicative of lesion malignancy;

• The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has, in fact, occurred;

• Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of rupture of epidermal inclusion (sebaceous) cyst.

• Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are present:

• Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding;

• Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patients;

• Lesions are condyloma acuminata or molluscum contagiosum;

• Cervical dysplasia or pregnancy is associated with genital warts.

Limitations:

Medicare will not pay for a separate E & M service on the same day as a minor surgical procedure unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient’s medical record and a modifier 25 should be used.

Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient’s medical record.

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Medical records maintained by the physician must clearly document the medical necessity for the lesion removal(s) if Medicare is billed for the service.

Drawings or diagrams to describe the precise anatomical location of the lesion are helpful. A procedural note, protocol describing indications, diagnosis, methodology of treatment, or modality is advised.

The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.

Documentation must be available to Medicare upon request.

Not applicable

Clinically, it would not be expected that any given lesion would have to be treated more than once in a six months interval. The intrinsic nature of the lesion will determine whether more frequent treatments are required.

This utilization guideline applies to all conditions within this LCD other than actinic keratosis.

Bibliography

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