Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)

LCD Information Document Information Source LCD ID N/A LCD ID L34233 Original ICD-9 LCD ID Not Applicable LCD Title Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) Proposed LCD in Comment Period N/A Source Proposed LCD DL34233 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 07/28/2016 Notice Period End Date 09/14/2016 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 update is to consolidate JE and JF to have one unified document and policy number. 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 medically reasonable and necessary. Title XVIII of the Social Security Act, §1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim. CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §250.4. Coverage Indications, Limitations, and/or Medical Necessity This policy applies to the following: seborrheic keratoses, skin tags, milia, molluscum contagiosum, sebaceous (epidermoid) cysts, moles (nevi), acquired hyperkeratosis (keratoderma) and viral warts (excluding condyloma acuminatum). The treatment of actinic keratosis is covered by NCD 250.4. This policy does not address routine foot care or the treatment of other skin lesions, e.g., ulcers, abscess, malignancies, dermatoses or psoriasis.Benign skin lesions are common in the elderly and are frequently removed at the patient’s request to improve appearance. Removal of benign skin lesions that do not pose a threat to health or function is considered cosmetic and as such is not covered by the Medicare program. Cosmesis is statutorily non-covered and no payment may be made for such lesion removal.Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or more of the following conditions is present and clearly documented in the medical record:A. The lesion has one or more of the following characteristics:1. bleeding 2. intense itching 3. pain B. The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema.C. The lesion obstructs an orifice or clinically restricts vision.D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction.E. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy.F. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction will be covered when the following clinical circumstance is present: Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding Evidence of spread from one body area to another, particularly in immunocompromised/immunosuppressed patients. If the beneficiary wishes one or more benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service(s) rendered. Regarding other Malignancy: If a diagnosis of malignancy has already been established for a specific lesion, a shave biopsy would not be medically reasonable and necessary. Compliance with the provisions in this policy may be subject to monitoring by post payment data analysis and subsequent medical review. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

This policy applies to the following: seborrheic keratoses, skin tags, milia, molluscum contagiosum, sebaceous (epidermoid) cysts, moles (nevi), acquired hyperkeratosis (keratoderma) and viral warts (excluding condyloma acuminatum). The treatment of actinic keratosis is covered by NCD 250.4. This policy does not address routine foot care or the treatment of other skin lesions, e.g., ulcers, abscess, malignancies, dermatoses or psoriasis. Benign skin lesions are common in the elderly and are frequently removed at the patient’s request to improve appearance. Removal of benign skin lesions that do not pose a threat to health or function is considered cosmetic and as such is not covered by the Medicare program. Cosmesis is statutorily non-covered and no payment may be made for such lesion removal. Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or more of the following conditions is present and clearly documented in the medical record: A. The lesion has one or more of the following characteristics: 1. bleeding 2. intense itching 3. pain B. The lesion has physical evidence of inflammation, e.g., purulence, oozing, edema, erythema. C. The lesion obstructs an orifice or clinically restricts vision. D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction. E. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy. F. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred. G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction will be covered when the following clinical circumstance is present: Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding Evidence of spread from one body area to another, particularly in immunocompromised/immunosuppressed patients. If the beneficiary wishes one or more benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service(s) rendered. Regarding other Malignancy: If a diagnosis of malignancy has already been established for a specific lesion, a shave biopsy would not be medically reasonable and necessary. Compliance with the provisions in this policy may be subject to monitoring by post payment data analysis and subsequent medical review.