About this policy
Jurisdiction: JJ Part B. States: Alabama, Georgia, Tennessee. Type: Active LCD
Coverage indications
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.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.