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Local Coverage Determination (LCD)

Removal of Benign and Malignant Skin Lesions

L33445

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

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
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/24/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/22/2016
Notice Period End Date
02/05/2017
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
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) services excluded from coverage-cosmetic surgery and related services

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §250.4 Treatment of Actinic Keratosis

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 16, §120 Cosmetic Surgery

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §60.1 Incident to Physician’s Professional Services

Coverage Guidance

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 LCD describes the medical conditions for which skin lesion removal using one of the services (eg., 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

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

In most situations, Medicare will not pay for a separate Evaluation and Management (E/M) service on the same day dermatologic surgery is performed unless significant and separately identifiable medical services were rendered and clearly documented in the patient's medical record.
Sources of Information
N/A
Bibliography

The Carrier Medical Director Workgroup on Dermatology

 

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/24/2019 R26

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Removal of Benign and Malignant Skin Lesions A56346 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
05/23/2019 R25

Under Coverage Indications, Limitations and/or Medical Necessity added the verbiage “of the related billing and coding article A56346” to the second sentence in the first paragraph. Formatting, punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
03/21/2019 R24

All verbiage regarding billing and coding under the Associated Information section has been removed and is included in the related Billing and Coding for Removal of Benign and Malignant Skin Lesions A56346 article.

  • Provider Education/Guidance
01/01/2019 R23

All coding located in the Coding Information section has been moved into the related Billing and Coding for Removal of Benign and Malignant Skin Lesions A56346 article and removed from the LCD. Under CPT/HCPCS Codes Group 1: Codes removed codes 11102, 11103, 11104, 11105, 11106 and 11107 being that the Removal of Benign and Malignant Skin Lesions LCD does not discuss biopsies.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Other (Code migration due to CR 10901)
01/01/2019 R22

Under CPT/HCPCS Codes Group 1: Codes added CPT codes 11102-11107. This revision is due to the Annual CPT/HCPCS Code Update.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
11/26/2018 R21

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added D23.111, D23.112, D23.121, and D23.122. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
  • Reconsideration Request
10/01/2018 R20

Under CPT/HCPCS Codes – Group 1: Codes added CPT® codes 17260,17261, 17262, 17263, 17264, 17266, 17270, 17271, 17272, 17273, 17274, 17276, 17280, 17281, 17282, 17283, 17284 and 17286. This revision is due to a reconsideration request.

Under ICD-10 Codes that Support Medical Necessity: Group 1 added ICD-10 codes C43.111, C43.112, C43.121, C43.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.131, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, C4A.111, C4A.112, C4A.121, C4A.122, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D22.111, D22.112, D22.121 and D22.122. Under ICD-10 Codes that Support Medical Necessity: Group 1 deleted ICD-10 codes C43.11, C43.12, C44.102, C44.109, C44.112, C44.119, C44.122, C44.129, C44.192, C44.199, C4A.11, C4A.12, D03.11, D03.12, D04.11, D04.12, D22.11, D22.12, D23.11 and D23.12. This revision is due to the 2018 Annual ICD-10 Code Update and is effective on October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Revisions Due To ICD-10-CM Code Changes
  • Reconsideration Request
07/19/2018 R19

Under Coverage Indications, Limitations and/or Medical Necessity revised the verbiage to add “etc.” to the following: “This LCD describes the medical conditions for which skin lesion removal using one of the services listed in the CPT section (shaving, removal, destruction, etc.) would be medically necessary and therefore not be excluded.”

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
03/30/2018 R18

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 code D29.0 due to a reconsideration request. ICD code D29.0 is valid only for CPT codes 11420, 11421, 11422, 11423, 11424 and 11426.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
  • Reconsideration Request
02/26/2018 R17 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R16 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/01/2018 R15

Under Coverage Indications, Limitations and/or Medical Necessity in the second paragraph added the following statement, “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.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
01/01/2018 R14

Under CPT/HCPCS Codes Group 1 the description was revised for CPT code 11403. This revision is due to the Annual CPT/HCPCS Code Update.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.


 

 
  • Revisions Due To CPT/HCPCS Code Changes
11/02/2017 R13

 

Under CPT/HCPCS Codes – Group 1: Codes the code description was changed for CPT code 11403. This revision is due to the Q4 CPT/HCPCS Update. This update became effective for dates of service beginning 10/2/2017.

 

 

10/20/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

 
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/16/2017 R12

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 code C63.2 due to a reconsideration request.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Reconsideration Request
10/01/2017 R11

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes C96.29 and D47.01. This revision is due to the 2017 Annual ICD-10 Code Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/02/2017 R10 Under ICD-10 Codes that Support Medical Necessity- ICD-10 codes added to Group 1: C51.0, C51.1, C51.2, C51.8, C51.9, C60.0, C60.1, C60.2, C60.8, C60.9, D28.0, D29.4.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
03/16/2017 R9 Under CMS National Coverage Policy- Grammatical correction to Internet Only Manual Pub 100-03, Chapter 1 Part 4, Section 250.4. Removed “excludes Medicare coverage for” and capitalized the “c” and “s” on cosmetic surgery. Grammatical correction to Pub 100-02, Chapter 15 Section 60.1. Capitalized lettering in title to read “Incident to Physician’s Professional Services”. Under Associated Information– Documentation Requirements - Added the header above second paragraph to state “Utilization Guidelines”. Code Description change for CPT code 11403 effective January 25, 2017 as per the 2017 Quarter 1 CPT HCPCS updates.
  • Provider Education/Guidance
  • Typographical Error
02/06/2017 R8 No comments were received from the provider community; therefore, no revisions were made.
  • Provider Education/Guidance
07/25/2016 R7 Under ICD-10 Codes that Support Medical Necessity added ICD-10 code D03.4.
  • Reconsideration Request
07/25/2016 R6 Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes C43.0, C43.11, C43.12, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8, C4A.0, C4A.11, C4A.12, C4A.21, C4A.22, C4A.31, C4A.39, C4A.4, C4A.52, C4A.59, C4A.61, C4A.62, C4A.71 and C4A.72.
  • Provider Education/Guidance
  • Reconsideration Request
04/08/2016 R5 Under CPT/HCPCS Codes added CPT codes 11600, 11601, 11602, 11603, 11604, 11606, 11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641 and 11642. Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes D03.0, D03.11, D03.12, D03.21, D03.22, D03.39, D03.51, D03.52, D03.59, D03.61, D03.62, D03.71, D03.72 and D03.8.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
  • Revisions Due To ICD-10-CM Code Changes
02/19/2016 R4 Under CMS National Coverage Policy deleted “this section” X3, deleted “medically” in the first citation, and in the second citation deleted “accidently” and revised it to now read “accidental”. Under Bill Type Codes deleted the bill types as per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. Under ICD-10 Codes That Support Medical Necessity deleted the *Note related to use of decimal points for ICD-10 codes. Under Associated Information-Documentation Requirements revised the last sentence to now read, “Use modifier 25 appended to the appropriate visit code to indicate that the patient's condition required a significant, separately identifiable service by the same physician on the same day of the procedure that was performed.”
  • Provider Education/Guidance
  • Typographical Error
10/01/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R2 This policy was revised to become an A/B policy.
  • Provider Education/Guidance
10/01/2015 R1 Under CMS National Coverage Policy removed “System” from each reference to CMS Internet-Only Manual. Un-italicized titles of Internet-Only Manuals.
  • Provider Education/Guidance
  • Other (Maintenance
    Annual Review)
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
10/14/2019 10/24/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Skin Lesions
  • Actinic Keratosis
  • Lesions

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