Removal of Benign and Malignant Skin Lesions

LCD Information Document Information Source LCD ID N/A LCD ID L33445 Original ICD-9 LCD ID Not Applicable LCD Title Removal of Benign and Malignant Skin Lesions Proposed LCD in Comment Period N/A Source Proposed LCD DL33445 Opens in a new window Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/23/2025 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/22/2016 Notice Period End Date 02/05/2017 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy 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 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) excludes Medicare coverage for cosmetic surgery, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member. 42 CFR 411.15(h) Particular services excluded from coverage: Cosmetic surgery and related servicesCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §250.4 Treatment of Actinic Keratosis CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §60.1 Incident to Physician’s Professional Services CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §120 Cosmetic Surgery Coverage Indications, Limitations, and/or Medical Necessity Benign skin lesions are common in the elderly and are sometimes removed at the patient's request. Removal 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 (statutory exclusion). This local coverage determination (LCD) describes the medical conditions for which skin lesion removal using one of the services (e.g., shaving, removal, destruction, etc.) listed in the CPT® section of the related billing and coding article A56346 would be medically necessary and would therefore not be excluded.Medicare would consider the removal of any malignant lesion to be medically necessary. Actinic keratosis removals are covered as per the requirements indicated in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §250.4.There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts 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 present and clearly documented in the medical record: The lesion has one or more of the following characteristics: Bleeding Persistent or intense itching Pain The lesion has physical evidence of inflammation (purulence, oozing, edema, erythema, etc.) The lesion obstructs an orifice or clinically restricts vision There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesional appearance, such as increased rate of growth and/or color changes The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred Wart destruction will be covered if it falls under one of the conditions of the first five bullets above. In addition, because warts are a viral infection of the skin, wart destruction will be covered when any one of the following clinical circumstances is present: Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding Warts of recent origin in immunosuppressed patients Lesions in sensitive anatomic locations that are non-problematic do not qualify for removal coverage on the basis of location alone.The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.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.Office visits will be covered when the diagnosis of a benign skin lesion(s) is made, even if the removal of a particular lesion(s) is not medically indicated and is therefore not done. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Benign skin lesions are common in the elderly and are sometimes removed at the patient's request. Removal 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 (statutory exclusion). This local coverage determination (LCD) describes the medical conditions for which skin lesion removal using one of the services (e.g., shaving, removal, destruction, etc.) listed in the CPT ® section of the related billing and coding article A56346 would be medically necessary and would therefore not be excluded. Medicare would consider the removal of any malignant lesion to be medically necessary. Actinic keratosis removals are covered as per the requirements indicated in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §250.4. There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts 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 present and clearly documented in the medical record: The lesion has one or more of the following characteristics: Bleeding Persistent or intense itching Pain The lesion has physical evidence of inflammation (purulence, oozing, edema, erythema, etc.) The lesion obstructs an orifice or clinically restricts vision There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesional appearance, such as increased rate of growth and/or color changes The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred Wart destruction will be covered if it falls under one of the conditions of the first five bullets above. In addition, because warts are a viral infection of the skin, wart destruction will be covered when any one of the following clinical circumstances is present: Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding Warts of recent origin in immunosuppressed patients Lesions in sensitive anatomic locations that are non-problematic do not qualify for removal coverage on the basis of location alone. The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. 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. Office visits will be covered when the diagnosis of a benign skin lesion(s) is made, even if the removal of a particular lesion(s) is not medically indicated and is therefore not done.