LCD : Removal of Benign Skin Lesions (L1865)

LCD for Removal of Benign Skin Lesions (L1865)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1865

LCD Title

Removal of Benign Skin Lesions

Contractor's Determination Number

L1865

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not 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, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Medicare Carrier's Manual, "Coverage and Limitation", Section 2329. Cosmetic Surgery.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
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New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 12/27/1996

Original Determination Ending Date

Revision Effective Date

For services performed on or after 03/31/2004

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Benign skin lesions are common in the elderly and are frequently removed at the patient’s request to improve appearance. Removals 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. Benign skin lesions to which the accompanying lesion removal policy applies are the following: seborrheic keratoses; sebaceous (epidermoid) cysts, and viral warts (excluding condyloma acuminatum).

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, (See IOM 100-2, Chpt 16, Sec. 120) if one or more of the following conditions is presented 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, etc.

c. The lesion obstructs an orifice or clinically restricts vision.

d. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance.

e. A prior biopsy suggests or is indicative of lesion malignancy.

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 the guidelines (a-f) above. In addition, wart destructions will be covered when any one of the following clinical circumstances is present:

1. periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding;

2. warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients.

3. lesions are condyloma acuminata or molluscum contagiosum.

4. cervical dysplasia or pregnancy associated with genital warts.

Benign skin lesion removals for reasons other than those given under the "Indications and Limitations of Coverage" above are considered to be cosmetic and will not be covered. These reasons include, but not limited to, emotional distress, "makeup trapping", and asymptomatic lesions in any anatomical location. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone.

Coverage Topic

Surgical Services

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

036X	Operating room services-general classification
049X	Ambulatory surgical care-general classification
076X	Treatment or observation room-general classification
094X	Other therapeutic services-general classification

CPT/HCPCS Codes

This policy includes CPT codes 11055-11057, which are used to describe the paring or cutting of corns and or calluses. Corns are always on the feet and, when the calluses are on the feet, they are a part of the routine foot care (RFC) exclusion. The ONLY circumstance that these codes can be considered in this Benign Skin Lesion Policy is when the callus is on a part of the body OTHER than the foot.

11055	PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION
11056	PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS
11057	PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS
11300 - 11313	SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS - SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM
11400 - 11446	EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS - EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM
17000 - 17004	DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION - DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS
17110	DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS
17340	CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE

ICD-9 Codes that Support Medical Necessity

This policy is informational, is not restrictive, and is not entered into the Artificial Intelligence system.

XX000

Not Applicable

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

1. Medical records maintained by the physician must clearly and unequivocally document the medical necessity for lesion removal(s) if Medicare is billed for the service.

2. A record of statement of "irritated skin lesion" will be insufficient justification for lesion removal when solely used to reference a patient’s complaint or a physician’s physical findings. Similarly, use of ICD.9 code 702.11 - "Inflamed seborrheic keratosis" - will be insufficient to justify lesion removal without medical record documentation of the patient’s symptoms and physical findings.

3. Claims filed for medically necessary lesion removals should reference both the ICD-9-CM lesion code and one or more of the applicable procedures.

4. 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 lesion excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.

5. The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It 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.

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

"Cosmetic and Reconstructive Procedures in Plastic Surgery", published by the American Society of Plastic and Reconstructive Surgeons, Inc., 1989.

Stone MS, Lynch PJ. Viral warts in Principles and Practices of Dermatology, Churchill Livingstone, 1990, pp 119-127.

Epstein, E. Dermatologic disorders in The Merck Manual, 16th ED., New Jersey: Merck and Co., Inc., 1992, pp 2399-2460.

Ho V, McLean DI. Benign epithelial tumors in Dermatology in General Medicine, 4th Ed., McGraw-Hill, Inc., pp 855-872.

Dermatology consultant expert opinion (various).

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

11/27/1996

Revision History Number

L1865a

Revision History Explanation

This LCD was converted from LMRP 037-96 on 3/30/2004

07/24/2002 Formatted

11/11/2000 ICD-9 codes were removed from policy.

02/22/2001 CPT codes checked with 2001 Code Book

11/07/2004 - The description for CPT/HCPCS code 17004 was changed in group 1

11/26/2005 - The description for CPT/HCPCS code 11440 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code 11441 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code 11442 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code 11443 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code 11444 was changed in group 1
11/26/2005 - The description for CPT/HCPCS code 11446 was changed in group 1

11/18/2006 - The description for CPT/HCPCS code 17000 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code 17003 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code 17004 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code 17110 was changed in group 1

10/30/2007 - Frequently Asked Questions restored to Appendices

11/10/2007 - The description for CPT/HCPCS code 11056 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code 11057 was changed in group 1
11/10/2007 - The description for CPT/HCPCS code 17110 was changed in group 1