Local Coverage Determination (LCD)

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

L34233

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Contractor Information

LCD Information

Document Information

LCD ID
L34233
LCD Title
Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34233
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/01/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
07/28/2016
Notice Period End Date
09/14/2016
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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 © 2021 American Dental Association. All rights reserved.

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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 Guidance

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

General Information

Associated Information
N/A
Sources of Information
National Model Policy developed by CMD Workgroup


Bibliography

N/A

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
10/01/2019 R9

As required by CR 10901, all billing and coding information has been moved to the companion article, this article is linked to 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.

 

  • Revisions Due To Code Removal
10/01/2019 R8

Revised the following statement in Indications and Limitations to include D48.5, "When a diagnosis of malignancy has not yet been established at the time the biopsy procedure was performed, the correct diagnosis code to list on the claim would most likely be D48.5 or D49.2." This diagnosis was already included in the ICD-10 codes supporting medical necessity. 

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.

 

  • Other (Provided clarity for coding a yet established malignancy at the time of biopsy.)
10/01/2018 R7

09.05.18: 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.

The following ICD-10 codes were deleted from the ICD-10 Codes that Support Medical Necessity field: C4A.11; C4A.12; C44.102; C44.109; C44.112; C44.119; C44.122; C44.129;C44.192; C44.199; D04.11;D04.12 were deleted from Group 4 and D22.11; D22.12; D23.11 D23.12 from group 2.

The following ICD-10 Codes were added to the ICD-10 Codes that Support Medical Necessity field to group four:C4A.111;C4A.112;C4A.121;C4A.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; C44.1921; C44.1922; C44.1991; C44.1992; D03.111;D03.112; D03.121; D03.122; D04.111; D04.112; D04.121; D04.122; Added to Group II: D22.111; D22.112; D22.121; D22.122; D23.111; D23.112; D23.121; D23.122. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R6 L72.3 is listed both in Group I and Group II codes. It is removed from Group I. L91.0 is moved from Group I and added to Group II. L91.8 is added to Group II. It was added to the previous JF LCD but was not included in the draft or final LCD when JE and JF contracts were combined making the policy consistent between the two contracts.
  • Reconsideration Request
10/01/2016 R5 This LCD was revised to include the following diagnosis codes effective 10/1/16: D49.511, D49512, D49.519, D49.59 to Group 1. Diagnosis code D49.5 is deleted in Group 1.
  • Revisions Due To ICD-10-CM Code Changes
09/15/2016 R4 This LCD version was created as a result of DL34233 being released to a Final LCD.
  • Creation of Uniform LCDs Within a MAC Jurisdiction
10/01/2015 R3 The last paragraph of Indications and Limitations was revised to change ICD-9 diagnosis 239.2 to ICD-10 diagnosis D49.2, effective 10/01/2015.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 Removed B07.0, L72.3 and L91.0 from Group 2 ICD-10 Codes as they were already listed as stand alone diagnoses in Group 1; Added L08.9 to Group 3. Changes added to provide clarity for these diagnosis codes.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 The Note in Coverage Indications, Limitations and/or Medical Necessity was revised to remove reference to 17106, 17107 and 17108 being addressed in a separate policy. It was also revised to state that when they are not used primarily for cosmetic reasons the medical record must indicate why the procedure is not cosmetic.
  • Typographical Error

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/18/2019 10/01/2019 - 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
  • lesion
  • basal
  • carcinoma
  • squamous
  • neoplasm
  • malignant
  • squamous
  • merkel
  • benign
  • nevi
  • sarcoid
  • abscess
  • cellulitis

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